=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659111243
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UTAH THYROID CENTER PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2024
-----------------------------------------------------
Last Update Date | 05/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2135 W MAIN ST STE B107
-----------------------------------------------------
City | LEHI
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84043-6936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-655-6415
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2135 W MAIN ST STE B107
-----------------------------------------------------
City | LEHI
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84043-6936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-655-6415
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER/MANAGER
-----------------------------------------------------
Name | KONSTANTINOS SEGKOS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 774-261-3957
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RE0101X
-----------------------------------------------------
Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------