Healthcare Provider Details

I. General information

NPI: 1902107618
Provider Name (Legal Business Name): ROURK N. BAIRD APC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2010
Last Update Date: 11/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7923 MAIN ST
MIDVALE UT
84047-7768
US

IV. Provider business mailing address

7923 MAIN ST
MIDVALE UT
84047-7768
US

V. Phone/Fax

Practice location:
  • Phone: 801-699-3309
  • Fax:
Mailing address:
  • Phone: 801-699-3309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6746508-6009
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: