Provider Demographics
NPI:1487529764
Name:IMPACT MEDICAL LLC
Entity type:Organization
Organization Name:IMPACT MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:FOGG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-712-2535
Mailing Address - Street 1:1776 N HIGHWAY 40, STE 101
Mailing Address - Street 2:
Mailing Address - City:HEBER CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84032
Mailing Address - Country:US
Mailing Address - Phone:435-294-2664
Mailing Address - Fax:801-274-0049
Practice Address - Street 1:1776 N HIGHWAY 40, STE 101
Practice Address - Street 2:
Practice Address - City:HEBER CITY
Practice Address - State:UT
Practice Address - Zip Code:84032
Practice Address - Country:US
Practice Address - Phone:435-294-2664
Practice Address - Fax:801-274-0049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-10-07
Last Update Date:2025-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty