| Utah Modern Medical Llc | |
|
14839 S Canyon Point Road Draper UT 84020-1489 | |
| (385) 414-2158 | |
| (888) 823-5887 |
| Full Name | Utah Modern Medical Llc |
|---|---|
| Speciality | General Practice |
| Location | 14839 S Canyon Point Road, Draper, Utah |
| Authorized Official Name and Position | Dave Bullock (OWNER) |
| Authorized Official Contact | 3854142158 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Utah Modern Medical Llc 14839 S Canyon Point Road Draper UT 84020-1489 Ph: (385) 414-2158 | Utah Modern Medical Llc 14839 S Canyon Point Road Draper UT 84020-1489 Ph: (385) 414-2158 |
| NPI Number | 1689310948 |
|---|---|
| Provider Enumeration Date | 05/10/2022 |
| Last Update Date | 07/07/2022 |
| Medicare PECOS PAC ID | 8729461728 |
|---|---|
| Medicare Enrollment ID | O20220823003069 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1689310948 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 208D00000X | General Practice | (* (Not Available)) | Primary |
| 363AM0700X | Physician Assistant - Medical | (* (Not Available)) | Secondary |
| Provider Name | Robert Whitney Slack |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1467467399 PECOS PAC ID: 5799672853 Enrollment ID: I20040303000090 |
| Provider Name | Spencer Lee Scoville |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1821192436 PECOS PAC ID: 5092758607 Enrollment ID: I20061026000484 |
| Provider Name | Michael Mark Koniuch |
|---|---|
| Provider Type | Practitioner - Physical Medicine And Rehabilitation |
| Provider Identifiers | NPI Number: 1225394612 PECOS PAC ID: 1759606049 Enrollment ID: I20160715000729 |
| Provider Name | Jesse Walker |
|---|---|
| Provider Type | Practitioner - Physical Medicine And Rehabilitation |
| Provider Identifiers | NPI Number: 1417452046 PECOS PAC ID: 5991138794 Enrollment ID: I20220721000928 |
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