MEDICARE: FAMILY SURGICAL SUITE

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	207L00000X	Anesthesiology Physician		UT

General Provider Information

NPI Number	:	1811146384
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY SURGICAL SUITE

Provider Business Mailing Address
First Line	:	PO BOX 2265
Second Line	:
City	:	SANDY
State	:	UT
Zip	:	84091-2265
Country	:	US
Telephone Number	:	801-495-1064
Fax Number	:	801-523-1139

Provider Business Practice Location Address
First Line	:	151 E 5600 S STE 104
Second Line	:
City	:	MURRAY
State	:	UT
Zip	:	84107-8140
Country	:	US
Telephone Number	:	801-495-1064
Fax Number	:	801-523-1139

Authorized Official
Title or Position	:	ADMIN.
Name	:	MRS. DAWN DEHART
Credential	:
Telephone Number	:	801-495-1064

Provider Enumeration Date	:	09/09/2008
Last Update Date	:	09/09/2008

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151 E 5600 S STE 104
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Directions to “FAMILY SURGICAL SUITE ” Practice Location

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