Provider Demographics
NPI:1720379936
Name:GREGORY IVERSON FAMILY MEDICINE PLLC
Entity Type:Organization
Organization Name:GREGORY IVERSON FAMILY MEDICINE PLLC
Other - Org Name:COALVILLE HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FAMILY PHYSICIAN/MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:DENNIS
Authorized Official - Last Name:IVERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:435-336-4403
Mailing Address - Street 1:PO BOX 865
Mailing Address - Street 2:
Mailing Address - City:COALVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84017-0865
Mailing Address - Country:US
Mailing Address - Phone:435-336-4403
Mailing Address - Fax:435-336-5570
Practice Address - Street 1:142 SOUTH 50 EAST
Practice Address - Street 2:
Practice Address - City:COALVILLE
Practice Address - State:UT
Practice Address - Zip Code:84017-0865
Practice Address - Country:US
Practice Address - Phone:435-336-4403
Practice Address - Fax:435-336-5570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-21
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7261660-1204261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health