Healthcare Provider Details

I. General information

NPI: 1316270655
Provider Name (Legal Business Name): GORDON R. KIMBALL M.D.,P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2009
Last Update Date: 07/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9844 S 1300 E SUITE 275
SANDY UT
84094-4673
US

IV. Provider business mailing address

9844 S 1300 E SUITE 275
SANDY UT
84094-4673
US

V. Phone/Fax

Practice location:
  • Phone: 801-571-7061
  • Fax: 801-572-4564
Mailing address:
  • Phone: 801-571-7061
  • Fax: 801-572-4564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number0551110013
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number1093777047
License Number StateUT

VIII. Authorized Official

Name: MRS. CARMA H MORGAN
Title or Position: OFFICE MANAGER
Credential:
Phone: 801-571-7061