MEDICARE: DR. BARRY DALE BERGQUIST MD

Medicare Provider Information

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207L00000X	Anesthesiology Physician	93-188635-1205	UT

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1502954	OTHER	UT	UMWA
3	8597445	OTHER	UT	WORKERS COMP FUND
4	870545614BE1	OTHER	UT	EDUCATORS MUTUAL
5	PRA04665	OTHER	UT	MOLINA
6	2090168	OTHER	UT	UNITED HEALTHCARE
7	96764	OTHER	UT	DESERET MUTUAL
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
9	107005508101	OTHER	UT	IHC
10	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
11	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
12	53226	OTHER	UT	HEALTHY U
13	37773	OTHER	UT	PEHP
14	QM0000075886	OTHER	UT	ALTIUS

NPI Number	:	1932118171
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BARRY DALE BERGQUIST MD

Provider Business Mailing Address
First Line	:	3340 NORTH CENTER ST #800
Second Line	:
City	:	LEHI
State	:	UT
Zip	:	84043-7406
Country	:	US
Telephone Number	:	801-990-1911
Fax Number	:	801-990-1912

Provider Business Practice Location Address
First Line	:	5121 S COTTONWOOD STREET
Second Line	:	INTERMOUNTAIN MEDICAL CENTER
City	:	MURRAY
State	:	UT
Zip	:	84157
Country	:	US
Telephone Number	:	801-507-5248
Fax Number	:	801-733-5618

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

Provider Enumeration Date	:	08/05/2006
Last Update Date	:	10/15/2012