Healthcare Provider Details

I. General information

NPI: 1518403641
Provider Name (Legal Business Name): SUMMIT PHYSICIAN SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2017
Last Update Date: 01/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5444 S GREEN ST
MURRAY UT
84123-5632
US

IV. Provider business mailing address

5444 S GREEN ST
MURRAY UT
84123-5632
US

V. Phone/Fax

Practice location:
  • Phone: 801-262-8120
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. DOUG HANSEN
Title or Position: CEO
Credential:
Phone: 801-284-1718