Healthcare Provider Details

I. General information

NPI: 1720379936
Provider Name (Legal Business Name): GREGORY IVERSON FAMILY MEDICINE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2011
Last Update Date: 11/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

142 SOUTH 50 EAST
COALVILLE UT
84017-0865
US

IV. Provider business mailing address

PO BOX 865
COALVILLE UT
84017-0865
US

V. Phone/Fax

Practice location:
  • Phone: 435-336-4403
  • Fax: 435-336-5570
Mailing address:
  • Phone: 435-336-4403
  • Fax: 435-336-5570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number7261660-1204
License Number StateUT

VIII. Authorized Official

Name: DR. GREGORY DENNIS IVERSON
Title or Position: FAMILY PHYSICIAN/MANAGING MEMBER
Credential: D.O.
Phone: 435-336-4403