| Health Diversified - Medical Group Of Utah Llc | |
|
4544 S Holladay Blvd Holladay UT 84117-4404 | |
| (801) 682-6817 | |
| (385) 213-0356 |
| Full Name | Health Diversified - Medical Group Of Utah Llc |
|---|---|
| Speciality | Clinic/Center |
| Location | 4544 S Holladay Blvd, Holladay, Utah |
| Authorized Official Name and Position | Ann Smith (AUTHORIZED OFFICIAL) |
| Authorized Official Contact | 8016826817 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Health Diversified - Medical Group Of Utah Llc 5986 S Tolcate Woods Ln Holladay UT 84121-1536 Ph: (801) 682-6817 | Health Diversified - Medical Group Of Utah Llc 4544 S Holladay Blvd Holladay UT 84117-4404 Ph: (801) 682-6817 |
| NPI Number | 1508518085 |
|---|---|
| Provider Enumeration Date | 01/25/2022 |
| Last Update Date | 09/15/2023 |
| Certification Date | 09/15/2023 |
| Medicare PECOS PAC ID | 8325401169 |
|---|---|
| Medicare Enrollment ID | O20230828001901 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1508518085 | NPI | - | NPPES |
| Provider Name | Douglas Roland Smith |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1174681928 PECOS PAC ID: 3274596184 Enrollment ID: I20041110001076 |
| Provider Name | Eric Scott Overton |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1225448327 PECOS PAC ID: 5092074773 Enrollment ID: I20180126000510 |
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