Provider Demographics
NPI:1699977496
Name:VALLEY OBSTETRICS AND GYNECOLOGY, PC
Entity type:Organization
Organization Name:VALLEY OBSTETRICS AND GYNECOLOGY, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:B
Authorized Official - Last Name:RASMUSSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-374-1801
Mailing Address - Street 1:585 N 500 W
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-1548
Mailing Address - Country:US
Mailing Address - Phone:801-374-1801
Mailing Address - Fax:801-216-8357
Practice Address - Street 1:585 N 500 W
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-1548
Practice Address - Country:US
Practice Address - Phone:801-374-1801
Practice Address - Fax:801-216-8357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT358469-8905207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870285509000Medicaid
UT000055309Medicare PIN