Provider Demographics
NPI:1902875669
Name:NORTHERN UTAH ENDOSCOPY CENTER
Entity Type:Organization
Organization Name:NORTHERN UTAH ENDOSCOPY CENTER
Other - Org Name:NORTHERN UTAH ENDOSCOPY CENTER, LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DUANE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-787-0270
Mailing Address - Street 1:630 E 1400 N
Mailing Address - Street 2:SUITE 100A
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-2534
Mailing Address - Country:US
Mailing Address - Phone:435-787-0270
Mailing Address - Fax:435-787-0262
Practice Address - Street 1:630 E 1400 N
Practice Address - Street 2:SUITE 100A
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2534
Practice Address - Country:US
Practice Address - Phone:435-787-0270
Practice Address - Fax:435-787-0262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-15
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2006-ASF-16794261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT490004876OtherRAILROAD MEDICARE
UT2006-ASF-16794OtherSTATE LICENSE
ID806091700Medicaid
WY116023100Medicaid
UT490004876OtherRAILROAD MEDICARE
UT000001067Medicare PIN