Healthcare Provider Details

I. General information

NPI: 1548683410
Provider Name (Legal Business Name): MARK MILES PASSEY MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2014
Last Update Date: 01/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5872 S 900 E 250
SALT LAKE CITY UT
84121-1676
US

IV. Provider business mailing address

48 W BROADWAY APT 2001
SALT LAKE CITY UT
84101-2015
US

V. Phone/Fax

Practice location:
  • Phone: 801-314-2308
  • Fax:
Mailing address:
  • Phone: 801-314-2308
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number81-167082-1205
License Number StateUT

VIII. Authorized Official

Name: MARK MILES PASSEY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 801-314-2308