Healthcare Provider Details

I. General information

NPI: 1609901610
Provider Name (Legal Business Name): MARK DOUGLAS EBERT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 08/23/2023
Certification Date: 08/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N MARIO CAPECCHI DR DEPT OF MEDICAL IMAGING
SALT LAKE CITY UT
84113-1103
US

IV. Provider business mailing address

100 N MARIO CAPECCHI DR DEPT OF MEDICAL IMAGING
SALT LAKE CITY UT
84113-1103
US

V. Phone/Fax

Practice location:
  • Phone: 801-875-1586
  • Fax:
Mailing address:
  • Phone: 801-875-1586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License NumberM-11694
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License NumberMED-PHYS-LIC-52597
License Number StateMT
# 3
Primary TaxonomyY
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number8209945-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: