Healthcare Provider Details

I. General information

NPI: 1518966399
Provider Name (Legal Business Name): SUMMIT PAIN MANAGEMENT PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5250 COMMERCE DR STE 305
MURRAY UT
84107-7926
US

IV. Provider business mailing address

PO BOX 27688
SALT LAKE CITY UT
84127-0688
US

V. Phone/Fax

Practice location:
  • Phone: 801-262-7246
  • Fax: 801-262-3696
Mailing address:
  • Phone: 801-534-1360
  • Fax: 801-366-9883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number9727-05
License Number StateUT

VIII. Authorized Official

Name: STEPHEN P LORDON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 801-262-7246