Healthcare Provider Details

I. General information

NPI: 1194825117
Provider Name (Legal Business Name): GINA M MUSCOLINO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 01/31/2022
Certification Date: 11/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 MEDICAL DR SUITE 340
BOUNTIFUL UT
84010-5084
US

IV. Provider business mailing address

PO BOX 409836
ATLANTA GA
30384-9836
US

V. Phone/Fax

Practice location:
  • Phone: 801-299-2229
  • Fax: 801-299-2230
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number036093446
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number7229132-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: