Healthcare Provider Details

I. General information

NPI: 1558597831
Provider Name (Legal Business Name): WADE FAMILY MEDICINE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2009
Last Update Date: 09/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

557 W 2600 S
BOUNTIFUL UT
84010-7747
US

IV. Provider business mailing address

557 W 2600 S
BOUNTIFUL UT
84010-7747
US

V. Phone/Fax

Practice location:
  • Phone: 801-298-9155
  • Fax: 801-298-9156
Mailing address:
  • Phone: 801-298-9155
  • Fax: 801-298-9156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number180211-1204
License Number StateUT

VIII. Authorized Official

Name: DR. RALPH D WADE
Title or Position: PRESIDENT
Credential: D.O.
Phone: 801-298-9155