Healthcare Provider Details

I. General information

NPI: 1770999807
Provider Name (Legal Business Name): MT OGDEN ANESTHESIA GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2014
Last Update Date: 06/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3480 WASHINGTON BLVD STE 105
OGDEN UT
84401-4149
US

IV. Provider business mailing address

PO BOX 837
OGDEN UT
84402-0837
US

V. Phone/Fax

Practice location:
  • Phone: 801-392-0385
  • Fax: 801-393-3334
Mailing address:
  • Phone: 801-392-0385
  • Fax: 801-393-3334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: LAYNE CROXFORD
Title or Position: CO-OWNER
Credential: CRNA
Phone: 801-392-0385