Healthcare Provider Details

I. General information

NPI: 1790794063
Provider Name (Legal Business Name): RICHARD L GLINES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 08/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 E 3900 S #30
SALT LAKE CITY UT
84124
US

IV. Provider business mailing address

PO BOX 271220
SALT LAKE CITY UT
84127-1220
US

V. Phone/Fax

Practice location:
  • Phone: 801-268-7725
  • Fax:
Mailing address:
  • Phone: 801-534-1360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number7596444-1205
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number7596444-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: