Provider Demographics
NPI:1770527871
Name:EAST LAYTON INTERNAL MEDICINE LLC
Entity type:Organization
Organization Name:EAST LAYTON INTERNAL MEDICINE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:KANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-568-5999
Mailing Address - Street 1:1240 EAST HIGHWAY 193
Mailing Address - Street 2:SUITE G-1
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84040
Mailing Address - Country:US
Mailing Address - Phone:801-475-8600
Mailing Address - Fax:801-771-1330
Practice Address - Street 1:1240 EAST HIGHWAY 193
Practice Address - Street 2:SUITE G-1
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84040
Practice Address - Country:US
Practice Address - Phone:801-475-8600
Practice Address - Fax:801-771-1330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DG2400Medicare PIN
UT000058129Medicare PIN