Healthcare Provider Details

I. General information

NPI: 1245220805
Provider Name (Legal Business Name): ROBERT D BIRCH DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 12/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 CHIPETA WAY SUITE 1214
SALT LAKE CITY UT
84108-0108
US

IV. Provider business mailing address

PO BOX 413076
SALT LAKE CITY UT
84141-3076
US

V. Phone/Fax

Practice location:
  • Phone: 801-585-1575
  • Fax:
Mailing address:
  • Phone: 801-213-3900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number22-156844-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: