Provider Demographics
NPI:1144648213
Name:GOURLEY ALLERGY & ASTHMA PC
Entity type:Organization
Organization Name:GOURLEY ALLERGY & ASTHMA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVIDS
Authorized Official - Middle Name:S
Authorized Official - Last Name:GOURLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-266-4115
Mailing Address - Street 1:4646 S FARM MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-8064
Mailing Address - Country:US
Mailing Address - Phone:801-278-0730
Mailing Address - Fax:
Practice Address - Street 1:6065 S FASHION BLVD
Practice Address - Street 2:STE 255
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-7381
Practice Address - Country:US
Practice Address - Phone:801-266-4115
Practice Address - Fax:801-266-4138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-04
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1838591205207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTE90878Medicare UPIN