Healthcare Provider Details

I. General information

NPI: 1598826422
Provider Name (Legal Business Name): BART W FOTHERINGHAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5810 SO 300 EAST SUITE #300
MURRAY UT
84107
US

IV. Provider business mailing address

5810 SO 300 EAST SUITE #300
MURRAY UT
84107
US

V. Phone/Fax

Practice location:
  • Phone: 801-314-2308
  • Fax: 801-314-2413
Mailing address:
  • Phone: 801-314-2308
  • Fax: 801-314-2413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number1877101205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: