Healthcare Provider Details

I. General information

NPI: 1720252117
Provider Name (Legal Business Name): MICHAEL COSGRAVE II D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2008
Last Update Date: 08/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 W SOUTH JORDAN PKWY SUITE 102
SOUTH JORDAN UT
84095-9060
US

IV. Provider business mailing address

1325 W SOUTH JORDAN PKWY SUITE 102
SOUTH JORDAN UT
84095-9060
US

V. Phone/Fax

Practice location:
  • Phone: 801-508-3111
  • Fax:
Mailing address:
  • Phone: 801-508-3111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number7397727-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: