MEDICARE: DR. CHARLOTTE ELAINE GANT M.D.

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	2084P0800X	Psychiatry Physician	831704181205	UT

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	A97112	OTHER	UT	MEDICARE ADVANTAGE
4	002200221	OTHER	UT	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	107006815101	OTHER	UT	INTERMOUNTAIN HEALTH CARE
2	942938348GA1	OTHER	UT	EDUCATORS MUTUAL
5	261775	OTHER	UT	DESERET MUTUAL
6	831704181205	OTHER	UT	STATE MEDICAL LICENSE
7	XXXX01001	OTHER		BLUE CROSS

General Provider Information

NPI Number	:	1518944818
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLOTTE ELAINE GANT M.D.

Provider Business Mailing Address
First Line	:	1020 S MAIN ST
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84101-3115
Country	:	US
Telephone Number	:	801-539-7000
Fax Number	:	801-539-7050

Provider Business Practice Location Address
First Line	:	1020 S MAIN ST
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84101-3115
Country	:	US
Telephone Number	:	801-539-7000
Fax Number	:	801-539-7050

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

Provider Enumeration Date	:	12/28/2005
Last Update Date	:	03/07/2023

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Directions to “ DR. CHARLOTTE ELAINE GANT M.D.” Practice Location

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