Provider Demographics
NPI:1811978620
Name:STATE OF UTAH
Entity type:Organization
Organization Name:STATE OF UTAH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:
Authorized Official - First Name:DALLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:EARNSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:801-344-4200
Mailing Address - Street 1:PO BOX 270
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84603-0270
Mailing Address - Country:US
Mailing Address - Phone:801-344-4400
Mailing Address - Fax:801-344-4225
Practice Address - Street 1:1300 E CENTER ST
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84606-3554
Practice Address - Country:US
Practice Address - Phone:801-344-4400
Practice Address - Fax:801-344-4225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-09
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTUT00882OtherMEDICARE B SUBMITTER ID
UTUT00882OtherMEDICARE B SUBMITTER ID
UT464001Medicare Oscar/Certification