Provider Demographics
NPI:1114096195
Name:PEDIATRIC CARDIOLOGY DEPARTMENT OF UNIVERSITY OF UTAH
Entity Type:Organization
Organization Name:PEDIATRIC CARDIOLOGY DEPARTMENT OF UNIVERSITY OF UTAH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPT CHAIR
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:B
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-587-7400
Mailing Address - Street 1:295 CHIPETA WAY
Mailing Address - Street 2:U OF U SOM DEPT OF PEDIATRICS
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1220
Mailing Address - Country:US
Mailing Address - Phone:801-587-7400
Mailing Address - Fax:801-587-7417
Practice Address - Street 1:100 MARIO CAPECCHI DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1103
Practice Address - Country:US
Practice Address - Phone:801-662-5400
Practice Address - Fax:801-662-5404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY121313000Medicaid
IN200817950AMedicaid
NV100507101Medicaid
CO22001832Medicaid
ID807148600Medicaid
OK200065910AMedicaid
WY121313000Medicaid
OK200065910AMedicaid