Provider Demographics
NPI:1043501257
Name:GREGORY IVERSON FAMILY MEDICINE, PLLC
Entity type:Organization
Organization Name:GREGORY IVERSON FAMILY MEDICINE, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FAMILY PHYSICIAN/MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:DENNIS
Authorized Official - Last Name:IVERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:435-336-4403
Mailing Address - Street 1:PO BOX 159
Mailing Address - Street 2:
Mailing Address - City:KAMAS
Mailing Address - State:UT
Mailing Address - Zip Code:84036-0159
Mailing Address - Country:US
Mailing Address - Phone:435-783-4385
Mailing Address - Fax:435-783-2919
Practice Address - Street 1:228 WEST 200 SOUTH
Practice Address - Street 2:
Practice Address - City:KAMAS
Practice Address - State:UT
Practice Address - Zip Code:84036-0159
Practice Address - Country:US
Practice Address - Phone:435-783-4385
Practice Address - Fax:435-783-2919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-21
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7261660-1204261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health