MEDICARE: MARK R BRIESACHER MD

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	208000000X	Pediatrics Physician	932637891205	UT

General Provider Information

NPI Number	:	1154333029
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK R BRIESACHER MD

Provider Business Mailing Address
First Line	:	PO BOX 27128
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84127-0128
Country	:	US
Telephone Number	:	801-278-4719
Fax Number	:

Provider Business Practice Location Address
First Line	:	2180 E 4500 S
Second Line	:	#210
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-4434
Country	:	US
Telephone Number	:	801-278-4719
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/12/2006
Last Update Date	:	12/01/2008

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Directions to “ MARK R BRIESACHER MD” Practice Location

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