Provider Demographics
NPI:1194723650
Name:MED ONE MEDICAL
Entity type:Organization
Organization Name:MED ONE MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:TREACY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-566-6433
Mailing Address - Street 1:6965 UNION PARK CTR
Mailing Address - Street 2:#400
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-6008
Mailing Address - Country:US
Mailing Address - Phone:801-566-6433
Mailing Address - Fax:801-304-0076
Practice Address - Street 1:6965 UNION PARK CTR
Practice Address - Street 2:#400
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-6008
Practice Address - Country:US
Practice Address - Phone:801-566-6433
Practice Address - Fax:801-304-0076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT17686261QS1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========00001OtherBCBS OF UT