Basic Information
| Provider Information | |||||||||
| NPI: | 1528066875 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BEAVER VALLEY HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1670 | ||||||||
| Address2: | 1109 N 100 W | ||||||||
| City: | BEAVER | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847131670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4354387100 | ||||||||
| FaxNumber: | 4354387166 | ||||||||
| Practice Location | |||||||||
| Address1: | 1109 N 100TH W | ||||||||
| Address2: | |||||||||
| City: | BEAVER | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847131670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4354387100 | ||||||||
| FaxNumber: | 4354387166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2005 | ||||||||
| LastUpdateDate: | 05/18/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DAVIDSON | ||||||||
| AuthorizedOfficialFirstName: | CRAIG | ||||||||
| AuthorizedOfficialMiddleName: | VAL | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4384387100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | 2006-HOSP-167 | UT | N | Hospital Units | Medicare Defined Swing Bed Unit | 282N00000X | 2004-HOSP-167 | UT | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 000006972 | 01 | UT | PART B LEGACY OR PTAN # | OTHER |