Provider Demographics
NPI:1982223848
Name:PHYSICIAN GROUP OF UTAH INC
Entity Type:Organization
Organization Name:PHYSICIAN GROUP OF UTAH INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/CMS DELEGATED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:M
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-562-5628
Mailing Address - Street 1:9 GALEN ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-4515
Mailing Address - Country:US
Mailing Address - Phone:617-562-5628
Mailing Address - Fax:
Practice Address - Street 1:1577 DEWAR DR STE 8
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-5716
Practice Address - Country:US
Practice Address - Phone:307-362-0707
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-10
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty