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NPI Code Detail

MEDICARE: MEDICAL DIRECTOR SERVICES, LLC

MEDICARE: MEDICAL DIRECTOR SERVICES, LLC
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
1174400000XSpecialist5049379-1205UT

General Provider Information

NPI Number : 1770751323
Entity Type Code : Organization
Provider Name (Legal Business Name) : MEDICAL DIRECTOR SERVICES, LLC
Provider Business Mailing Address
First Line : PO BOX 71840
Second Line :
City : SALT LAKE CITY
State : UT
Zip : 84171-0840
Country : US
Telephone Number : 801-809-9471
Fax Number : 801-572-1497
Provider Business Practice Location Address
First Line : 50 E 9000 S
Second Line :
City : SANDY
State : UT
Zip : 84070-2201
Country : US
Telephone Number : 801-561-9839
Fax Number :
Authorized Official
Title or Position : PRESIDENT/PHYSICIAN
Name : KAVITA G WILLESEN
Credential : M.D.
Telephone Number : 801-809-9471
Provider Enumeration Date : 02/18/2008
Last Update Date : 04/17/2008

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