MEDICARE: JEREMIAH J MAXWELL CST

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	246ZC0007X	Surgical Assistant
2	246ZS0410X	Surgical Technologist

General Provider Information

NPI Number	:	1780089268
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEREMIAH J MAXWELL CST

Provider Business Mailing Address
First Line	:	2513 W 2400 S
Second Line	:
City	:	HEBER CITY
State	:	UT
Zip	:	84032-3624
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2513 W 2400 S
Second Line	:
City	:	HEBER CITY
State	:	UT
Zip	:	84032-3624
Country	:	US
Telephone Number	:	435-671-0838
Fax Number	:

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

Provider Enumeration Date	:	10/27/2014
Last Update Date	:	10/27/2014

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