Provider Demographics
NPI:1548261290
Name:CENTRAL UTAH RADIOLOGY, PC
Entity type:Organization
Organization Name:CENTRAL UTAH RADIOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:MITCHELL
Authorized Official - Last Name:VAIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-623-3000
Mailing Address - Street 1:48 W 1500 N
Mailing Address - Street 2:
Mailing Address - City:NEPHI
Mailing Address - State:UT
Mailing Address - Zip Code:84648-8900
Mailing Address - Country:US
Mailing Address - Phone:435-623-3000
Mailing Address - Fax:
Practice Address - Street 1:48 W 1500 N
Practice Address - Street 2:
Practice Address - City:NEPHI
Practice Address - State:UT
Practice Address - Zip Code:84648-8900
Practice Address - Country:US
Practice Address - Phone:435-623-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-03
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========001Medicaid
UTDA0435Medicare PIN
UT000007026Medicare PIN