Unknown Individual – Family Medicine Physician, NPI 1205897196

Family Medicine Physician

Unknown Individual is a healthcare provider. based in Roosevelt, Utah. specializing in Family Medicine Physician. They hold a License No. 1482551205 (UT). The NPI Number for Unknown Individual is 1205897196

Main info

Organization

Inactive

62 Years Of Experience

Accepts Medicare Assignment

Name

Unknown Individual

NPI

1205897196

Phone

(435) 722-3971

Address

210 W 300 N

Deactivation Date

20 September 2022

Doctor Profile

Medical School Name

GEORGE WASHINGTON UNIVERSITY SCHOOL OF MEDICINE

Secondary Phone

4357224691

Graduation Year

1964 (62 years ago)

PAC ID

2163563008

Group Practice PAC ID

2961496609

Professional Enrollment ID

I20100114000063

Data current as of

19 May 2026

Profile Insights

NPPES metrics only — not quality of care.

Methodology

Experience14

Completeness75

Years active:0State licenses:1Digital endpointsOther names

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Provider Addresses for Unknown Individual

210, West 300 North, Roosevelt, Duchesne County, Utah, 84066, United States
75-3
ROOSEVELT, UT 840662336
Phone: (435) 722-3971
Fax: (435) 722-6104
Mailing address matches the actual address.

NPPES updates history

No NPPES updates recorded for this provider.

Prescription Activity

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Open Payments (CMS)

No Open Payments data available for this provider.

This can happen when there are no reportable CMS Open Payments records.

Medicare Enrollment & Revalidation

Source: CMS public data · Not endorsed by CMS ·

Educational use only—not medical, billing, or legal advice.

No Medicare enrollment or revalidation data available for this provider in our database.

Prepare CMS-855 application → · Look up this NPI in PECOS → · Verify on CMS PECOS

Medicare Utilization (FFS)

Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·

Educational use only—not medical, billing, or legal advice.

No Medicare fee-for-service utilization data available for this provider in our database.

Insurance plans in this area (ZIP 84066)

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Provider's Procedures

Unknown Individual performs procedures in Family Medicine Physician. See the list of HCPCS codes below.

Specialty	Practice State	HCPCS Code	Description	Service Count	Beneficiary Count
GENERAL PRACTICE	UT	45378	Diagnostic examination of large bowel using an endoscope	31	30

Group practice members

Group practice members are other physicians who share the same Group Practice PAC ID with this doctor. When doctors form a group practice and register in PECOS as a single entity, they receive a shared identification number. This table lists all providers in the same group practice.

PAC ID: 2961496609View full group profile

Name	Specialty	State
MR. ALEC HIGGINS JR. RIMMASCH (NP-C)	-	UT
DR. DARWIN L MCKEE (P.A.-C)	Physician Assistant	UT
KERRY ROBERT JR. BAUM (MD)	General Surgery	UT
KHURRAM BILAL TARIQ (M.D.)	H E M A T O L O G Y/ O N C O L O G Y	GA
NATHAN ROBERT PETERSON (M.D.)	Medical Oncology, Hematology/Oncology, Internal Medicine	UT
DR. GREGORY L STAKER (MD)	Internal Medicine	UT
DR. JAMES D WHITE (MD)	Physical Medicine And Rehabilitation	UT
DR. PHILLIP BLAINE WHITING (M.D.)	O T O L A R Y N G O L O G Y	CO
MICHAEL OLSEN (M.D.)	Family Practice	UT
KINSEY REYNOLDS (MS, PA-C)	Physician Assistant	UT