Provider Demographics
NPI:1528070489
Name:MOAB FAMILY MEDICINE PC
Entity type:Organization
Organization Name:MOAB FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:LEWIS
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-259-7121
Mailing Address - Street 1:476 WILLIAMS WAY STE A
Mailing Address - Street 2:PO BOX 1270
Mailing Address - City:MOAB
Mailing Address - State:UT
Mailing Address - Zip Code:84532-2065
Mailing Address - Country:US
Mailing Address - Phone:435-259-7121
Mailing Address - Fax:435-259-3112
Practice Address - Street 1:476 WILLIAMS WAY
Practice Address - Street 2:A
Practice Address - City:MOAB
Practice Address - State:UT
Practice Address - Zip Code:84532-2065
Practice Address - Country:US
Practice Address - Phone:435-259-7121
Practice Address - Fax:435-259-3112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1542OtherBUSINESS LICENSE
UT46D1056014OtherCLIA
UT46D1056014OtherCLIA
UTU000076893Medicare PIN