Provider Demographics
NPI:1174062376
Name:DR. BRIAN LILJENQUIST PLLC
Entity type:Organization
Organization Name:DR. BRIAN LILJENQUIST PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LILJENQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:801-869-4100
Mailing Address - Street 1:1250 E 3900 S STE 440
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1349
Mailing Address - Country:US
Mailing Address - Phone:801-869-4100
Mailing Address - Fax:801-869-4119
Practice Address - Street 1:1250 E 3900 S STE 440
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124
Practice Address - Country:US
Practice Address - Phone:801-869-4100
Practice Address - Fax:801-869-4119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-21
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9140789-1205207Q00000X
UT8763069-1204208600000X, 2086S0127X, 261QM1300X
UT83699990501213ES0103X
UT292357-24012251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma SurgeryGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatricsGroup - Multi-Specialty