Healthcare Provider Details

I. General information

NPI: 1164557583
Provider Name (Legal Business Name): BRYAN C TAGGE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 S 900 E
SALT LAKE CITY UT
84102-1307
US

IV. Provider business mailing address

22 S 900 E
SALT LAKE CITY UT
84102-1307
US

V. Phone/Fax

Practice location:
  • Phone: 801-328-2522
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number4881588-8905
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: