MEDICARE: GATEWAY AESTHEETIC INSTITUTE& LASER CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	284300000X	Special Hospital	158056-8905	UT

General Provider Information

NPI Number	:	1124208343
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GATEWAY AESTHEETIC INSTITUTE& LASER CENTER

Provider Business Mailing Address
First Line	:	440 W 200 S STE 250
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84101-1462
Country	:	US
Telephone Number	:	801-595-1600
Fax Number	:	801-364-0423

Provider Business Practice Location Address
First Line	:	440 W 200 S STE 250
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84101-1462
Country	:	US
Telephone Number	:	801-595-1600
Fax Number	:	801-364-0423

Authorized Official
Title or Position	:	CEO/PHYSICIAN
Name	:	MR. MARK B TAYLOR
Credential	:	M.D.
Telephone Number	:	801-595-1600

Provider Enumeration Date	:	11/05/2007
Last Update Date	:	11/05/2007

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Directions to “GATEWAY AESTHEETIC INSTITUTE& LASER CENTER ” Practice Location

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