Healthcare Provider Details

I. General information

NPI: 1144648213
Provider Name (Legal Business Name): GOURLEY ALLERGY & ASTHMA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2014
Last Update Date: 04/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6065 S FASHION BLVD STE 255
MURRAY UT
84107-7381
US

IV. Provider business mailing address

4646 S FARM MEADOW LN
SALT LAKE CITY UT
84117-8064
US

V. Phone/Fax

Practice location:
  • Phone: 801-266-4115
  • Fax: 801-266-4138
Mailing address:
  • Phone: 801-278-0730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number1838591205
License Number StateUT

VIII. Authorized Official

Name: DR. DAVIDS S GOURLEY
Title or Position: MANAGING MEMBER
Credential: MD
Phone: 801-266-4115