Provider Demographics
NPI:1285604462
Name:GIOVANNIELLO, MICHAEL THOMAS (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:THOMAS
Last Name:GIOVANNIELLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10011 S CENTENNIAL PKWY
Mailing Address - Street 2:STE 500
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070
Mailing Address - Country:US
Mailing Address - Phone:801-676-7627
Mailing Address - Fax:801-676-7630
Practice Address - Street 1:10011 S CENTENNIAL PKWY
Practice Address - Street 2:STE 500
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070
Practice Address - Country:US
Practice Address - Phone:801-676-7627
Practice Address - Fax:801-676-7630
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT49069701205208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1316160534OtherGROUP NPI
UTG73180Medicare UPIN