| Uaf Legacy Health | |
|
150 S 1000 E Salt Lake City UT 84102-1443 | |
| (801) 487-2323 | |
| (801) 486-3987 |
| Full Name | Uaf Legacy Health |
|---|---|
| Speciality | Clinic/Center |
| Location | 150 S 1000 E, Salt Lake City, Utah |
| Authorized Official Name and Position | Ian Mcmahan (VP OF CLINICAL OPERATIONS & TECHNOL) |
| Authorized Official Contact | 8014872323 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Uaf Legacy Health 150 S 1000 E Salt Lake City UT 84102-1443 Ph: (801) 487-2323 | Uaf Legacy Health 150 S 1000 E Salt Lake City UT 84102-1443 Ph: (801) 487-2323 |
| NPI Number | 1720702434 |
|---|---|
| Provider Enumeration Date | 09/27/2022 |
| Last Update Date | 07/12/2023 |
| Medicare PECOS PAC ID | 2668834326 |
|---|---|
| Medicare Enrollment ID | O20230811000867 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1720702434 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM1300X | Clinic/center - Multi-specialty | (* (Not Available)) | Primary |
| Provider Name | Susan W Keeshin |
|---|---|
| Provider Type | Practitioner - Pediatric Medicine |
| Provider Identifiers | NPI Number: 1871780676 PECOS PAC ID: 9537331384 Enrollment ID: I20140731001558 |
| Provider Name | Matthew Thomas Bryan |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1720349814 PECOS PAC ID: 3779804869 Enrollment ID: I20150601002251 |
| Provider Name | Sally Bowen |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1285256453 PECOS PAC ID: 3375974850 Enrollment ID: I20230928000608 |
| Provider Name | Drew Gary Olsen |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1972083947 PECOS PAC ID: 6800245663 Enrollment ID: I20231206000899 |
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