MEDICARE: R C HALVERSEN MD PC

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	208600000X	Surgery Physician

General Provider Information

NPI Number	:	1346255098
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	R C HALVERSEN MD PC

Provider Business Mailing Address
First Line	:	1160 E 3900 S
Second Line	:	4100
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124
Country	:	US
Telephone Number	:	801-268-3800
Fax Number	:	801-268-3997

Provider Business Practice Location Address
First Line	:	1160 E 3900 S
Second Line	:	4100
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124
Country	:	US
Telephone Number	:	801-268-3800
Fax Number	:	801-268-3997

Authorized Official
Title or Position	:	BILLING MGR
Name	:	MARY D SCOTT
Credential	:
Telephone Number	:	801-577-7055

Provider Enumeration Date	:	07/30/2006
Last Update Date	:	07/19/2011

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