Healthcare Provider Details

I. General information

NPI: 1760814834
Provider Name (Legal Business Name): SANDMAN PHYSICIAN SERVICES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2013
Last Update Date: 07/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

637 SEGO LILY CIR
NORTH SALT LAKE UT
84054-3355
US

IV. Provider business mailing address

637 SEGO LILY CIR
NORTH SALT LAKE UT
84054-3355
US

V. Phone/Fax

Practice location:
  • Phone: 801-209-7348
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LH0002X
TaxonomyHospice and Palliative Medicine (Anesthesiology) Physician
License Number75964441205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number75964441205
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number75964441205
License Number StateUT

VIII. Authorized Official

Name: DR. RICHARD L GLINES
Title or Position: PRESIDENT
Credential: MD
Phone: 801-209-7348