Healthcare Provider Details

I. General information

NPI: 1972696425
Provider Name (Legal Business Name): BENJAMIN J KROGH DO PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 10/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

822 EAST MAIN STREET #7
GRANTSVILLE UT
84029
US

IV. Provider business mailing address

822 EAST MAIN STREET #7
GRANTSVILLE UT
84029
US

V. Phone/Fax

Practice location:
  • Phone: 435-884-3582
  • Fax: 435-884-3578
Mailing address:
  • Phone: 435-884-3582
  • Fax: 435-884-3578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number8502
License Number StateUT

VIII. Authorized Official

Name: BENJAMIN J KROGH
Title or Position: PRESIDENT
Credential: D.O.
Phone: 435-884-3582