MEDICARE: DALLAS C OVERLY MPT

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	4910375-2401	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	49103752400001	OTHER	UT	BLUE CROSS
2	201776	OTHER	UT	ALTIUS
3	49103752410001	OTHER	UT	BCBS
4	1558317743	OTHER	UT	SELECT HEALTH
5	49103752403001	OTHER	UT	WRHN
6	88748	OTHER	UT	PEHP
7	49103752402001	OTHER	UT	WRHN/VALUECARE

General Provider Information

NPI Number	:	1558317743
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DALLAS C OVERLY MPT

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	:	13 E CENTER
Second Line	:
City	:	GUNNISON
State	:	UT
Zip	:	84634-0396
Country	:	US
Telephone Number	:	435-528-7575
Fax Number	:	435-528-7000

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

Provider Enumeration Date	:	05/26/2006
Last Update Date	:	10/10/2007

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Directions to “ DALLAS C OVERLY MPT” Practice Location

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