Healthcare Provider Details

I. General information

NPI: 1669440269
Provider Name (Legal Business Name): BRIAN G CRANDALL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 01/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 N 500 E STE 320
LOGAN UT
84341-2408
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-507-3513
  • Fax:
Mailing address:
  • Phone: 801-507-3513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number175425-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number175425-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: