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NPI Code Detail

MEDICARE: BLAKE C. MORTENSON M.D.

MEDICARE: BLAKE C. MORTENSON M.D.
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
12085R0202XDiagnostic Radiology Physician48375961205UT

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1427056860
Entity Type Code : Individual
Provider Name (Legal Business Name) : BLAKE C. MORTENSON M.D.
Provider Business Mailing Address
First Line : PO BOX 1108
Second Line :
City : BOUNTIFUL
State : UT
Zip : 84011-1108
Country : US
Telephone Number : 801-296-2113
Fax Number : 801-296-1715
Provider Business Practice Location Address
First Line : 1400 N 500 E
Second Line :
City : LOGAN
State : UT
Zip : 84341-2455
Country : US
Telephone Number : 435-716-1000
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/11/2005
Last Update Date : 04/20/2015

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