MEDICARE: NATHAN G MOMBERGER MD PC

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	207XS0114X	Adult Reconstructive Orthopaedic Surgery Physician	3208681205	UT

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	:	1366624991
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NATHAN G MOMBERGER MD PC

Provider Business Mailing Address
First Line	:	5848 FASHION BLVD STE 110
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84107-6121
Country	:	US
Telephone Number	:	801-314-5026
Fax Number	:	801-314-4015

Provider Business Practice Location Address
First Line	:	5848 FASHION BLVD STE 110
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84107-6121
Country	:	US
Telephone Number	:	801-314-5026
Fax Number	:	801-314-4015

Authorized Official
Title or Position	:	BUSINESS ADMINISTRATOR
Name	:	GENE R OAKES
Credential	:	CPA
Telephone Number	:	801-314-5026

Provider Enumeration Date	:	12/05/2007
Last Update Date	:	11/10/2010

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