Healthcare Provider Details

I. General information

NPI: 1366262487
Provider Name (Legal Business Name): IMPACT PHYSICIAN GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2024
Last Update Date: 10/14/2024
Certification Date: 10/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5825 HARRISON BLVD
SOUTH OGDEN UT
84403-4316
US

IV. Provider business mailing address

PO BOX 744577
ATLANTA GA
30374-4577
US

V. Phone/Fax

Practice location:
  • Phone: 801-475-5254
  • Fax:
Mailing address:
  • Phone:
  • Fax: 844-440-2328

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: PAUL MILLER
Title or Position: CEO
Credential:
Phone: 678-967-5599