Provider Demographics
NPI:1831568906
Name:PALLIATIVE SPECIALTY GROUP LLC
Entity type:Organization
Organization Name:PALLIATIVE SPECIALTY GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-930-5266
Mailing Address - Street 1:1106 E 6600 S
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-2446
Mailing Address - Country:US
Mailing Address - Phone:801-930-5266
Mailing Address - Fax:801-930-5272
Practice Address - Street 1:1106 E 6600 S
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84121-2446
Practice Address - Country:US
Practice Address - Phone:801-930-5266
Practice Address - Fax:801-930-5272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-18
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5096442-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty