Provider Demographics
NPI:1215918297
Name:PATCH, GREGORY G (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:G
Last Name:PATCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:PO BOX 25488
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0488
Mailing Address - Country:US
Mailing Address - Phone:800-475-3698
Mailing Address - Fax:801-296-6199
Practice Address - Street 1:1433 N 1075 W STE 104
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:UT
Practice Address - Zip Code:84025-2746
Practice Address - Country:US
Practice Address - Phone:801-299-2200
Practice Address - Fax:801-296-6199
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT180827-1205207U00000X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT266077OtherDESERET MUTUAL BENEFITS ADMINISTRATORS
UT300064158OtherRAILROAD MEDICARE
UTD0957Medicaid
UT107007749104OtherSELECTHEALTH
UT$$$$$$$$$04001OtherBCBS OF UTAH
B63906Medicare UPIN
UT$$$$$$$$$04001OtherBCBS OF UTAH
UT107007749104OtherSELECTHEALTH