Provider Demographics
NPI:1306952783
Name:EXODUS HEALTHCARE NETWORK PLLC
Entity type:Organization
Organization Name:EXODUS HEALTHCARE NETWORK PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MD OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:ZEHNDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-250-9638
Mailing Address - Street 1:3665 S 8400 W
Mailing Address - Street 2:STE 110
Mailing Address - City:MAGNA
Mailing Address - State:UT
Mailing Address - Zip Code:84044-4907
Mailing Address - Country:US
Mailing Address - Phone:801-250-9638
Mailing Address - Fax:801-250-3204
Practice Address - Street 1:3665 S 8400 W
Practice Address - Street 2:STE 110
Practice Address - City:MAGNA
Practice Address - State:UT
Practice Address - Zip Code:84044-4907
Practice Address - Country:US
Practice Address - Phone:801-250-9638
Practice Address - Fax:801-250-3204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870488410005Medicaid
UT870488410005Medicaid
UT5543370001Medicare NSC
UT000057005Medicare PIN