=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366624991
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NATHAN G MOMBERGER MD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2007
-----------------------------------------------------
Last Update Date | 11/10/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5848 FASHION BLVD STE 110
-----------------------------------------------------
City | SALT LAKE CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84107-6121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-314-5026
-----------------------------------------------------
Fax | 801-314-4015
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5848 FASHION BLVD STE 110
-----------------------------------------------------
City | SALT LAKE CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84107-6121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-314-5026
-----------------------------------------------------
Fax | 801-314-4015
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS ADMINISTRATOR
-----------------------------------------------------
Name | GENE R OAKES
-----------------------------------------------------
Credential | CPA
-----------------------------------------------------
Telephone | 801-314-5026
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207XS0114X
-----------------------------------------------------
Taxonomy Name | Adult Reconstructive Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 3208681205
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------