=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902875669
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHERN UTAH ENDOSCOPY CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2006
-----------------------------------------------------
Last Update Date | 04/28/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 630 E 1400 N SUITE 100A
-----------------------------------------------------
City | LOGAN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84341-2534
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-787-0270
-----------------------------------------------------
Fax | 435-787-0262
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 630 E 1400 N SUITE 100A
-----------------------------------------------------
City | LOGAN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84341-2534
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-787-0270
-----------------------------------------------------
Fax | 435-787-0262
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | DR. DUANE BOHMAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 435-787-0270
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 2006-ASF-16794
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------