Provider Demographics
NPI:1154508653
Name:INTERMOUNTAIN HEALTHCARE
Entity Type:Organization
Organization Name:INTERMOUNTAIN HEALTHCARE
Other - Org Name:PRIMARY CHILDREN'S MEDICAL CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:MEDICAL DIRECTOR, PED CRIT CARE
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:VERNON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-662-2427
Mailing Address - Street 1:100 N MEDICAL DR
Mailing Address - Street 2:PCMC
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84113-1103
Mailing Address - Country:US
Mailing Address - Phone:801-662-2442
Mailing Address - Fax:801-662-2469
Practice Address - Street 1:100 N MEDICAL DR
Practice Address - Street 2:PCMC
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1103
Practice Address - Country:US
Practice Address - Phone:801-662-2442
Practice Address - Fax:801-662-2469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-28
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT218983-4405282NC2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC2000XHospitalsGeneral Acute Care HospitalChildren