Provider Demographics
NPI:1053408450
Name:KENNETH L CRUMP MD PC
Entity type:Organization
Organization Name:KENNETH L CRUMP MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:L
Authorized Official - Last Name:CRUMP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-434-7600
Mailing Address - Street 1:811 N. 900 W.
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057
Mailing Address - Country:US
Mailing Address - Phone:801-434-7600
Mailing Address - Fax:801-434-7604
Practice Address - Street 1:811 N 900 W
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-7701
Practice Address - Country:US
Practice Address - Phone:801-434-7600
Practice Address - Fax:801-434-7604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT942752821205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000057521Medicare PIN
UT000012275Medicare PIN