MEDICARE: DR. PHIL STEPHEN HAGGERTY D.O.

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	207Q00000X	Family Medicine Physician	5426482-1204	UT

General Provider Information

NPI Number	:	1922000496
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PHIL STEPHEN HAGGERTY D.O.

Provider Business Mailing Address
First Line	:	461 E 200 S
Second Line	:	SUITE 100
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84111-2102
Country	:	US
Telephone Number	:	801-949-8312
Fax Number	:	801-553-9562

Provider Business Practice Location Address
First Line	:	461 E 200 S
Second Line	:	SUITE 100
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84111-2102
Country	:	US
Telephone Number	:	801-949-8312
Fax Number	:	801-553-9562

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

Provider Enumeration Date	:	08/12/2005
Last Update Date	:	07/08/2007

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