=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255422192
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRUCE E THOMAS MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2006
-----------------------------------------------------
Last Update Date | 01/04/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5957 FASHION POINT DR SUITE 101
-----------------------------------------------------
City | OGDEN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84403-5180
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-475-5683
-----------------------------------------------------
Fax | 801-475-9499
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1055 N 500 W
-----------------------------------------------------
City | PROVO
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84604-3305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-375-8858
-----------------------------------------------------
Fax | 801-418-0941
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207XX0005X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Orthopaedic Surgery) Physician
-----------------------------------------------------
License Number | 5181983-1205
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 5181983-1205
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------