Healthcare Provider Details

I. General information

NPI: 1699112086
Provider Name (Legal Business Name): PATRICK CARROLL MCKENZIE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2013
Last Update Date: 12/17/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 N MEDICAL DR
SALT LAKE CITY UT
84132-1622
US

IV. Provider business mailing address

30 N 1900 E RM 4R118
SALT LAKE CITY UT
84132-0002
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-7803
  • Fax:
Mailing address:
  • Phone: 801-585-0553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number10226566-1205
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number49426
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: