Healthcare Provider Details

I. General information

NPI: 1194076398
Provider Name (Legal Business Name): BRIDGE MEDICAL CONSULTING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2012
Last Update Date: 12/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4501 S HAWARDEN DR
WEST VALLEY UT
84119-5763
US

IV. Provider business mailing address

4501 S HAWARDEN DR
WEST VALLEY UT
84119-5763
US

V. Phone/Fax

Practice location:
  • Phone: 801-520-1007
  • Fax:
Mailing address:
  • Phone: 801-520-1007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. MARY D SCOTT
Title or Position: OFFICE MANAGER
Credential:
Phone: 801-647-8888