Provider Demographics
NPI:1316270655
Name:GORDON R. KIMBALL M.D.,P.C.
Entity type:Organization
Organization Name:GORDON R. KIMBALL M.D.,P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARMA
Authorized Official - Middle Name:H
Authorized Official - Last Name:MORGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-571-7061
Mailing Address - Street 1:9844 S 1300 E
Mailing Address - Street 2:SUITE 275
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-4673
Mailing Address - Country:US
Mailing Address - Phone:801-571-7061
Mailing Address - Fax:801-572-4564
Practice Address - Street 1:9844 S 1300 E
Practice Address - Street 2:SUITE 275
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-4673
Practice Address - Country:US
Practice Address - Phone:801-571-7061
Practice Address - Fax:801-572-4564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-17
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1093777047363AS0400X
UT0551110013207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT999000116008Medicaid
UT1578545919OtherINDIVIDUAL NPI
UTU000000781Medicare PIN
UT999000116008Medicaid
5635760001Medicare NSC