Provider Demographics
NPI:1447644240
Name:NOEL NELLIS, MD
Entity type:Organization
Organization Name:NOEL NELLIS, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN & SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:NOEL
Authorized Official - Middle Name:
Authorized Official - Last Name:NELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-479-9715
Mailing Address - Street 1:831 E 5875 S
Mailing Address - Street 2:
Mailing Address - City:SOUTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405-4997
Mailing Address - Country:US
Mailing Address - Phone:801-479-9715
Mailing Address - Fax:801-479-9452
Practice Address - Street 1:831 E 5875 S
Practice Address - Street 2:
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-4997
Practice Address - Country:US
Practice Address - Phone:801-479-9715
Practice Address - Fax:801-479-9452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-19
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT146023-1205261Q00000X, 261QU0200X, 305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No305S00000XManaged Care OrganizationsPoint of Service