Basic Information
| Provider Information | |||||||||
| NPI: | 1386825024 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLEBY | ||||||||
| FirstName: | CRAIG | ||||||||
| MiddleName: | ALAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12391 S 4000 W | ||||||||
| Address2: | STE 100 | ||||||||
| City: | RIVERTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840967012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013021700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 12391 S 4000 W | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | RIVERTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840967012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013021700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2007 | ||||||||
| LastUpdateDate: | 01/21/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 7637496-1205 | UT | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 7637496-1205 | UT | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080S0010X | 7637496-1205 | UT | N | Allopathic & Osteopathic Physicians | Pediatrics | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1386825024 | 05 | UT | MEDICAID |