Healthcare Provider Details

I. General information

NPI: 1780563171
Provider Name (Legal Business Name): ALISTAIR GUMMOW MB BCHIR FRCR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2025
Last Update Date: 08/29/2025
Certification Date: 08/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 NORTH MEDICAL DRIVE DEPARTMENT OF RADIOLOGY
SALT LAKE CITY UT
84132-0001
US

IV. Provider business mailing address

30 NORTH MARIO CAPECCHI DRIVE
SALT LAKE CITY UT
84112
US

V. Phone/Fax

Practice location:
  • Phone: 801-213-2789
  • Fax:
Mailing address:
  • Phone: 801-213-2789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number14212689-1251
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: