Provider Demographics
NPI:1679784102
Name:WIRT A HINES MD PC
Entity type:Organization
Organization Name:WIRT A HINES MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:WIRT
Authorized Official - Middle Name:A
Authorized Official - Last Name:HINES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-266-3400
Mailing Address - Street 1:1121 E 3900 S
Mailing Address - Street 2:C 125
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1214
Mailing Address - Country:US
Mailing Address - Phone:801-266-3400
Mailing Address - Fax:801-266-3401
Practice Address - Street 1:1121 E 3900 S
Practice Address - Street 2:C 125
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1214
Practice Address - Country:US
Practice Address - Phone:801-266-3400
Practice Address - Fax:801-266-3401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT150583-1205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD99454Medicare UPIN