Provider Demographics
NPI:1225295520
Name:PRIMARY CHILDREN'S MEDICAL CENTER
Entity Type:Organization
Organization Name:PRIMARY CHILDREN'S MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIR OF PEDIATRICS
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-662-1000
Mailing Address - Street 1:100 N MEDICAL DR
Mailing Address - Street 2:PRIMARY CHILDREN'S MEDICAL CENTER PEDIATRIC CARDIOLOGY
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84113-1103
Mailing Address - Country:US
Mailing Address - Phone:801-662-5400
Mailing Address - Fax:801-662-5404
Practice Address - Street 1:100 N MEDICAL DR
Practice Address - Street 2:PRIMARY CHILDREN'S MEDICAL CENTER PEDIATRIC CARDIOLOGY
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1103
Practice Address - Country:US
Practice Address - Phone:810-662-5400
Practice Address - Fax:801-662-5404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6138575-1204282NC2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC2000XHospitalsGeneral Acute Care HospitalChildren