MEDICARE: DEREK RAY ELLGEN DPT

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	225100000X	Physical Therapist	10448742-2401	UT

General Provider Information

NPI Number	:	1548783707
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEREK RAY ELLGEN DPT

Provider Business Mailing Address
First Line	:	PO BOX 396
Second Line	:
City	:	GUNNISON
State	:	UT
Zip	:	84634-0396
Country	:	US
Telephone Number	:	435-528-7575
Fax Number	:	435-528-7000

Provider Business Practice Location Address
First Line	:	1050 S MEDICAL DR STE A
Second Line	:
City	:	MOUNT PLEASANT
State	:	UT
Zip	:	84647-2200
Country	:	US
Telephone Number	:	435-462-0178
Fax Number	:	435-462-5252

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

Provider Enumeration Date	:	07/19/2017
Last Update Date	:	03/17/2018

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