Provider Demographics
NPI:1003825928
Name:UNIVERSITY OF UTAH PEDIATRIC PLASTIC SURGERY
Entity Type:Organization
Organization Name:UNIVERSITY OF UTAH PEDIATRIC PLASTIC SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CONTRACTING AND PE
Authorized Official - Prefix:
Authorized Official - First Name:JANELL
Authorized Official - Middle Name:I
Authorized Official - Last Name:MADONNA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-587-6464
Mailing Address - Street 1:PO BOX 58049
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84158-0049
Mailing Address - Country:US
Mailing Address - Phone:801-581-7073
Mailing Address - Fax:
Practice Address - Street 1:50 N MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0001
Practice Address - Country:US
Practice Address - Phone:801-581-2121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-07
Last Update Date:2009-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========001Medicaid