Healthcare Provider Details

I. General information

NPI: 1972759371
Provider Name (Legal Business Name): REBECCA LEVINE, MD, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2008
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1575 W 7000 S
WEST JORDAN UT
84084-3431
US

IV. Provider business mailing address

PO BOX 413008
SALT LAKE CITY UT
84141-0001
US

V. Phone/Fax

Practice location:
  • Phone: 801-569-9113
  • Fax: 801-569-9103
Mailing address:
  • Phone: 801-569-9119
  • Fax: 801-569-9103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number33292020-1205
License Number StateUT

VIII. Authorized Official

Name: REBECCA LEVINE
Title or Position: OWNER / MD
Credential: MD
Phone: 801-569-9119