Provider Demographics
NPI:1124135462
Name:BIRCH, RICHARD GLEN (DO)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:GLEN
Last Name:BIRCH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 N 400 E
Mailing Address - Street 2:
Mailing Address - City:PANGUITCH
Mailing Address - State:UT
Mailing Address - Zip Code:84759-0389
Mailing Address - Country:US
Mailing Address - Phone:435-676-8811
Mailing Address - Fax:435-676-2679
Practice Address - Street 1:200 N 400 E
Practice Address - Street 2:
Practice Address - City:PANGUITCH
Practice Address - State:UT
Practice Address - Zip Code:84759-0389
Practice Address - Country:US
Practice Address - Phone:435-676-8811
Practice Address - Fax:435-676-2679
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT273038-1204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD0451Medicaid
UTD0451Medicaid