| Bristol Advanced Illness Management | |
|
206 N 2100 W Ste 202 Salt Lake City UT 84116-4741 | |
| (801) 325-0175 | |
| (801) 478-3588 |
| Full Name | Bristol Advanced Illness Management |
|---|---|
| Speciality | Internal Medicine |
| Location | 206 N 2100 W Ste 202, Salt Lake City, Utah |
| Authorized Official Name and Position | Brandy Pratt (PRESIDENT) |
| Authorized Official Contact | 5737603730 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Bristol Advanced Illness Management 206 N 2100 W Ste 202 Salt Lake City UT 84116-4741 Ph: (801) 325-0175 | Bristol Advanced Illness Management 206 N 2100 W Ste 202 Salt Lake City UT 84116-4741 Ph: (801) 325-0175 |
| NPI Number | 1467930552 |
|---|---|
| Provider Enumeration Date | 08/01/2018 |
| Last Update Date | 01/06/2023 |
| Certification Date | 01/06/2023 |
| Medicare PECOS PAC ID | 6507190626 |
|---|---|
| Medicare Enrollment ID | O20190624003050 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1467930552 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YM0800X | Counselor - Mental Health | (* (Not Available)) | Secondary |
| 207RH0002X | Internal Medicine - Hospice And Palliative Medicine | (* (Not Available)) | Primary |
| Provider Name | Michael B Royall |
|---|---|
| Provider Type | Practitioner - Emergency Medicine |
| Provider Identifiers | NPI Number: 1346532694 PECOS PAC ID: 3870710239 Enrollment ID: I20140807001488 |
| Provider Name | Ryan Scott Larsen |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1669968723 PECOS PAC ID: 6709122617 Enrollment ID: I20190115001031 |
| Provider Name | Amy Lee Stone |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1922676915 PECOS PAC ID: 7517365596 Enrollment ID: I20211005002201 |
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