MEDICARE: NORTHERN UTAH IMAGING LLC

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	2085R0202X	Diagnostic Radiology Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00141132	OTHER	UT	RR MEDICARE

General Provider Information

NPI Number	:	1487643904
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHERN UTAH IMAGING LLC

Provider Business Mailing Address
First Line	:	3738 S 900 E
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-1913
Country	:	US
Telephone Number	:	801-313-1955
Fax Number	:	801-313-1965

Provider Business Practice Location Address
First Line	:	3738 S 900 E
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-1913
Country	:	US
Telephone Number	:	801-313-1955
Fax Number	:	801-313-1965

Authorized Official
Title or Position	:	IMAGING & ONCOLOGY MANAGED CARE
Name	:	MR. LAVELLE HARDIN
Credential	:
Telephone Number	:	615-372-5441

Provider Enumeration Date	:	10/18/2005
Last Update Date	:	11/08/2010

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Directions to “NORTHERN UTAH IMAGING LLC ” Practice Location

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