Healthcare Provider Details

I. General information

NPI: 1669546743
Provider Name (Legal Business Name): WIRT A HINES II MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 E 3900 S SUITE C-125
SALT LAKE CITY UT
84124-1214
US

IV. Provider business mailing address

1121 E 3900 S SUITE C-125
SALT LAKE CITY UT
84124-1214
US

V. Phone/Fax

Practice location:
  • Phone: 801-266-3400
  • Fax: 801-266-3401
Mailing address:
  • Phone: 801-266-3400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number1505831205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: