Provider Demographics
NPI:1194876078
Name:SAVAGE, SHELLY (MD, LLC)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:SAVAGE
Suffix:
Gender:F
Credentials:MD, LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-1341
Mailing Address - Country:US
Mailing Address - Phone:801-373-2001
Mailing Address - Fax:801-373-4748
Practice Address - Street 1:1900 N STATE ST
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-1341
Practice Address - Country:US
Practice Address - Phone:801-373-2001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4775407-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT47754071201001OtherBCBS OF UTAH
UT01-01807OtherUNITED HEALTHCARE
UT731282OtherDMBA
UT107008791102OtherINTERMOUNTAIN HEALTHCARE
UT68627OtherPEHP
UT216829OtherEMIA
UT005597801Medicare PIN
UT47754071201001OtherBCBS OF UTAH