Provider Demographics
NPI:1447468293
Name:ELY, BRIAN M (DO)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:M
Last Name:ELY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:PO BOX 510708
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84151-0708
Mailing Address - Country:US
Mailing Address - Phone:801-213-3900
Mailing Address - Fax:801-585-3655
Practice Address - Street 1:5126 W DAYBREAK PKWY
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-5994
Practice Address - Country:US
Practice Address - Phone:801-213-4500
Practice Address - Fax:801-213-5368
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH58.001871207Q00000X
UT8488408-1204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2809410Medicaid