Healthcare Provider Details

I. General information

NPI: 1902805948
Provider Name (Legal Business Name): UT CENTER FOR PAIN MANAGEMENT AND RESEARCH, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 09/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3585 N UNIVERSITY AVE STE 150
PROVO UT
84604-6630
US

IV. Provider business mailing address

3585 N UNIVERSITY AVE STE 150
PROVO UT
84604-6630
US

V. Phone/Fax

Practice location:
  • Phone: 801-356-6100
  • Fax: 801-356-2113
Mailing address:
  • Phone: 801-356-6100
  • Fax: 801-356-2113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number43731
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number43731
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number43731
License Number StateUT

VIII. Authorized Official

Name: RICHARD M ROSENTHAL
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 801-356-6100