Healthcare Provider Details

I. General information

NPI: 1154515765
Provider Name (Legal Business Name): TIMOTHY J GAYOWSKI MD FACS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2007
Last Update Date: 12/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

144 S 500 E
SALT LAKE CITY UT
84102-1907
US

IV. Provider business mailing address

DEPARTMENT OF SURGERY 30 NORTH 1900 EAST #3B110 SOM
SALT LAKE CITY UT
84132-0001
US

V. Phone/Fax

Practice location:
  • Phone: 775-222-0043
  • Fax: 800-704-8908
Mailing address:
  • Phone: 801-581-6171
  • Fax: 801-581-4359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number6668569-8905
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number6668569-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: