Healthcare Provider Details

I. General information

NPI: 1033734611
Provider Name (Legal Business Name): STEPHEN GREN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2020
Last Update Date: 06/10/2020
Certification Date: 06/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5121 S COTTONWOOD ST
MURRAY UT
84107-5701
US

IV. Provider business mailing address

2530 E LYNWOOD DR
SALT LAKE CITY UT
84109-1607
US

V. Phone/Fax

Practice location:
  • Phone: 801-507-7000
  • Fax:
Mailing address:
  • Phone: 801-915-4333
  • Fax: 801-915-4333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: