MEDICARE: CENTRAL UTAH CLINIC, P.C.

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	261QR0200X	Radiology Clinic/Center		UT

General Provider Information

NPI Number	:	1174642102
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRAL UTAH CLINIC, P.C.

Provider Business Mailing Address
First Line	:	1055 N 500 W
Second Line	:	ATTN: CREDENTIALING
City	:	PROVO
State	:	UT
Zip	:	84604-3305
Country	:	US
Telephone Number	:	801-354-8225
Fax Number	:	801-418-0941

Provider Business Practice Location Address
First Line	:	1490 E FOREMASTER DR BLDG C
Second Line	:
City	:	ST GEORGE
State	:	UT
Zip	:	84790-4550
Country	:	US
Telephone Number	:	435-986-2238
Fax Number	:	435-986-2237

Authorized Official
Title or Position	:	DIRECTOR OF MANAGED CARE
Name	:	JED HARSTON
Credential	:
Telephone Number	:	801-812-5012

Provider Enumeration Date	:	03/29/2007
Last Update Date	:	03/07/2018

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