Healthcare Provider Details

I. General information

NPI: 1972078723
Provider Name (Legal Business Name): PHYSICIAN MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2018
Last Update Date: 02/12/2020
Certification Date: 02/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4624 S HOLLADAY BLVD STE 202
SALT LAKE CITY UT
84117-7168
US

IV. Provider business mailing address

4624 S HOLLADAY BLVD STE 202
SALT LAKE CITY UT
84117-7168
US

V. Phone/Fax

Practice location:
  • Phone: 385-800-5015
  • Fax: 801-277-6678
Mailing address:
  • Phone: 801-810-2999
  • Fax: 801-407-0747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: JENNY SIMBARI
Title or Position: BILLER
Credential:
Phone: 385-800-5015