Provider Demographics
NPI:1194824201
Name:PROVO DIALYSIS CENTER UNIVERSITY OF UTAH
Entity Type:Organization
Organization Name:PROVO DIALYSIS CENTER UNIVERSITY OF UTAH
Other - Org Name:UNIVERSITY OF UTAH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROGRAM ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:HEMMING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-581-8573
Mailing Address - Street 1:PO BOX 27071
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0071
Mailing Address - Country:US
Mailing Address - Phone:801-581-8578
Mailing Address - Fax:801-374-1989
Practice Address - Street 1:1675 N FREEDOM BLVD
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-2540
Practice Address - Country:US
Practice Address - Phone:801-373-0167
Practice Address - Fax:801-374-1989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2004-ESRD-228261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT462504Medicare Oscar/Certification