MEDICARE: MOAB FAMILY MEDICINE 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	207Q00000X	Family Medicine Physician		UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1542	OTHER	UT	BUSINESS LICENSE
2	46D1056014	OTHER	UT	CLIA

General Provider Information

NPI Number	:	1528070489
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOAB FAMILY MEDICINE PC

Provider Business Mailing Address
First Line	:	476 WILLIAMS WAY STE A
Second Line	:	PO BOX 1270
City	:	MOAB
State	:	UT
Zip	:	84532-2065
Country	:	US
Telephone Number	:	435-259-7121
Fax Number	:	435-259-3112

Provider Business Practice Location Address
First Line	:	476 WILLIAMS WAY
Second Line	:	A
City	:	MOAB
State	:	UT
Zip	:	84532-2065
Country	:	US
Telephone Number	:	435-259-7121
Fax Number	:	435-259-3112

Authorized Official
Title or Position	:	OWNER/PHYSICIAN/PARTNER
Name	:	DR. KENNETH LEWIS WILLIAMS
Credential	:	MD
Telephone Number	:	435-259-7121

Provider Enumeration Date	:	08/12/2006
Last Update Date	:	05/20/2016

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Directions to “MOAB FAMILY MEDICINE PC ” Practice Location

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