Healthcare Provider Details

I. General information

NPI: 1700820941
Provider Name (Legal Business Name): PHYSICAL MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 04/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1424 E FOREMASTER DR # 120
ST GEORGE UT
84790
US

IV. Provider business mailing address

1424 E FOREMASTER DR # 120
ST GEORGE UT
84790
US

V. Phone/Fax

Practice location:
  • Phone: 435-656-8800
  • Fax: 435-627-1809
Mailing address:
  • Phone: 435-656-8800
  • Fax: 435-627-1809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number1765711205
License Number StateUT

VIII. Authorized Official

Name: DR. BRADLEY ROOT
Title or Position: PHYSICIAN
Credential: D.O.
Phone: 435-656-8800