Provider Demographics
NPI:1306076625
Name:FORT DUCHESNE INDIAN HEALTH CENTER RADIOLOGY
Entity type:Organization
Organization Name:FORT DUCHESNE INDIAN HEALTH CENTER RADIOLOGY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:DELBERT
Authorized Official - Middle Name:GARY
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:435-725-6874
Mailing Address - Street 1:6822 EAST 1000 SOUTH
Mailing Address - Street 2:
Mailing Address - City:FORT DUCHESNE
Mailing Address - State:UT
Mailing Address - Zip Code:84026
Mailing Address - Country:US
Mailing Address - Phone:435-725-6874
Mailing Address - Fax:435-725-6889
Practice Address - Street 1:6822 EAST 1000 SOUTH
Practice Address - Street 2:
Practice Address - City:FORT DUCHESNE
Practice Address - State:UT
Practice Address - Zip Code:84026
Practice Address - Country:US
Practice Address - Phone:435-725-6874
Practice Address - Fax:435-725-6889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-21
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT700000000009Medicaid
UTD07808Medicare UPIN
UTHSZ216Medicare PIN