Provider Demographics
NPI:1003069246
Name:TED R SCHULTZ MD LLC
Entity Type:Organization
Organization Name:TED R SCHULTZ MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TED
Authorized Official - Middle Name:R
Authorized Official - Last Name:SCHULTZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-202-4892
Mailing Address - Street 1:555 E 4500 S
Mailing Address - Street 2:C150
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-4533
Mailing Address - Country:US
Mailing Address - Phone:801-288-0747
Mailing Address - Fax:801-288-0761
Practice Address - Street 1:866 PADLEY ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1414
Practice Address - Country:US
Practice Address - Phone:801-202-4892
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-31
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT348875-1205208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005514106Medicare PIN
UTG91411Medicare UPIN