MEDICARE: HTI PHYSICIAN SERVICES OF UTAH INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR1300X	Rural Health Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104869965
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HTI PHYSICIAN SERVICES OF UTAH INC

Provider Business Mailing Address
First Line	:	1717 ARLINGTON AVE
Second Line	:
City	:	CALDWELL
State	:	ID
Zip	:	83605-4802
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	112 S PLYMOUTH STREET
Second Line	:
City	:	NEW PLYMOUTH
State	:	ID
Zip	:	83655-0048
Country	:	US
Telephone Number	:	208-278-3406
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MRS. JULIE TAYLOR
Credential	:
Telephone Number	:	208-455-3718

Provider Enumeration Date	:	06/13/2006
Last Update Date	:	10/26/2011

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