Healthcare Provider Details

I. General information

NPI: 1235557257
Provider Name (Legal Business Name): ERIC ROBERT BUELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2014
Last Update Date: 09/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N MARIO CAPECCHI DR
SALT LAKE CITY UT
84113-1103
US

IV. Provider business mailing address

PO BOX 3870
SALT LAKE CITY UT
84110-3870
US

V. Phone/Fax

Practice location:
  • Phone: 617-662-3577
  • Fax:
Mailing address:
  • Phone: 801-662-3578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License Number11225878-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: