Healthcare Provider Details

I. General information

NPI: 1588802961
Provider Name (Legal Business Name): UROLOGIC SURGERY ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2009
Last Update Date: 01/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11179 IVY CREEK CV
SOUTH JORDAN UT
84095-2249
US

IV. Provider business mailing address

11179 IVY CREEK CV
SOUTH JORDAN UT
84095-2249
US

V. Phone/Fax

Practice location:
  • Phone: 801-822-2727
  • Fax:
Mailing address:
  • Phone: 801-822-2727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QL0400X
TaxonomyLithotripsy Clinic/Center
License Number7100427-1205
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number7100427-1205
License Number StateUT

VIII. Authorized Official

Name: DR. DAN HIBBERT
Title or Position: MANAGER
Credential: MD
Phone: 801-822-2727