MEDICARE: MR. GREGORY ALLEN RUGG M.ED

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	101YM0800X	Mental Health Counselor	282617-6009	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	28261760000001	OTHER	UT	BLUE CROSS PROVIDER #

General Provider Information

NPI Number	:	1184694200
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GREGORY ALLEN RUGG M.ED

Provider Business Mailing Address
First Line	:	1958 MEADOWLAND AVE
Second Line	:
City	:	WEST JORDAN
State	:	UT
Zip	:	84084-2311
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3610 SOUTH 1000 WEST
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84119-2311
Country	:	US
Telephone Number	:	801-288-8400
Fax Number	:

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

Provider Enumeration Date	:	01/23/2006
Last Update Date	:	07/08/2007

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