Provider Demographics
NPI:1811146384
Name:FAMILY SURGICAL SUITE
Entity type:Organization
Organization Name:FAMILY SURGICAL SUITE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN.
Authorized Official - Prefix:MRS
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:DEHART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-495-1064
Mailing Address - Street 1:PO BOX 2265
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84091-2265
Mailing Address - Country:US
Mailing Address - Phone:801-495-1064
Mailing Address - Fax:801-523-1139
Practice Address - Street 1:151 E 5600 S STE 104
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-8140
Practice Address - Country:US
Practice Address - Phone:801-495-1064
Practice Address - Fax:801-523-1139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-09
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty