Provider Demographics
NPI:1215192026
Name:MYELOMA CARE DEPARTMENT OF UNIVERSITY OF UTAH
Entity Type:Organization
Organization Name:MYELOMA CARE DEPARTMENT OF UNIVERSITY OF UTAH
Other - Org Name:UUMC - MYELOMA CARE
Other - Org Type:Doing Business As
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 413033
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84141-0001
Mailing Address - Country:US
Mailing Address - Phone:801-581-2121
Mailing Address - Fax:
Practice Address - Street 1:1950 CIRCLE OF HOPE DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84112-5500
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:2008-07-21
Last Update Date:2009-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808154300 - MIDMedicaid
ID808115200Medicaid
UTDN9494OtherRR MEDICARE
UT000064335Medicare PIN