Healthcare Provider Details

I. General information

NPI: 1205030038
Provider Name (Legal Business Name): BRADLEY CRIS COWLEY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2007
Last Update Date: 11/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 ROUND VALLEY DR
PARK CITY UT
84060-7552
US

IV. Provider business mailing address

PO BOX 30180
SALT LAKE CITY UT
84130-0180
US

V. Phone/Fax

Practice location:
  • Phone: 435-658-7000
  • Fax:
Mailing address:
  • Phone: 919-330-6519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number9434743-1204
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO-R-8166
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: