MEDICARE: GARY L HALVERSEN MD

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	2085R0202X	Diagnostic Radiology Physician	1619861205	UT

General Provider Information

NPI Number	:	1740286970
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GARY L HALVERSEN MD

Provider Business Mailing Address
First Line	:	1151 E 3900 S
Second Line	:	#B150
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-1216
Country	:	US
Telephone Number	:	801-262-3441
Fax Number	:	801-269-9005

Provider Business Practice Location Address
First Line	:	1151 E 3900 S
Second Line	:	#B150
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-1216
Country	:	US
Telephone Number	:	801-262-3441
Fax Number	:	801-269-9005

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/22/2005
Last Update Date	:	09/30/2013

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Directions to “ GARY L HALVERSEN MD” Practice Location

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