Provider Demographics
NPI:1104324904
Name:BRIDGE UTAH MEDICAL GROUP
Entity type:Organization
Organization Name:BRIDGE UTAH MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER, MANAGING PAR
Authorized Official - Prefix:
Authorized Official - First Name:CAMERON
Authorized Official - Middle Name:G
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-598-8337
Mailing Address - Street 1:PO BOX 1468
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84011-1468
Mailing Address - Country:US
Mailing Address - Phone:888-853-8973
Mailing Address - Fax:888-959-9385
Practice Address - Street 1:1015 E 100 N
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-4873
Practice Address - Country:US
Practice Address - Phone:888-221-0423
Practice Address - Fax:888-221-9816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-26
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT0000Medicaid