Healthcare Provider Details

I. General information

NPI: 1962439570
Provider Name (Legal Business Name): GORDON PETTY GEORGE, MD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 N 700 W STE 340A
OREM UT
84057
US

IV. Provider business mailing address

255 S ALPINE DR
ALPINE UT
84004-1748
US

V. Phone/Fax

Practice location:
  • Phone: 801-431-0100
  • Fax: 801-431-7354
Mailing address:
  • Phone: 801-431-0100
  • Fax: 801-431-7354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number166871 1205
License Number StateUT

VIII. Authorized Official

Name: DR. GORDON P GEORGE
Title or Position: PRESIDENT
Credential: MD
Phone: 801-431-0100