MEDICARE: PHYSICIANS SERVICE GROUP, INC.

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	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1568644771
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHYSICIANS SERVICE GROUP, INC.

Provider Business Mailing Address
First Line	:	PO BOX 9126
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109-0126
Country	:	US
Telephone Number	:	801-664-1281
Fax Number	:

Provider Business Practice Location Address
First Line	:	7369 EAST 2223 SOUTH
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109
Country	:	US
Telephone Number	:	801-664-1281
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	GUY KIM DEHART
Credential	:
Telephone Number	:	801-664-1281

Provider Enumeration Date	:	11/29/2007
Last Update Date	:	11/29/2007

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