Provider Demographics
NPI:1265468524
Name:UNIVERSITY OF UTAH DEPARTMENT OF OB-GYN
Entity Type:Organization
Organization Name:UNIVERSITY OF UTAH DEPARTMENT OF OB-GYN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPARTMENT CHAIR
Authorized Official - Prefix:
Authorized Official - First Name:C. MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-581-2719
Mailing Address - Street 1:PO BOX 413028
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84141-3028
Mailing Address - Country:US
Mailing Address - Phone:801-213-3900
Mailing Address - Fax:
Practice Address - Street 1:50 N MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0001
Practice Address - Country:US
Practice Address - Phone:801-581-2719
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207VC0200XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyCritical Care MedicineGroup - Multi-Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY121965100OtherWYOMING MEDICAID
ID003022600OtherIDAHO MEDICAID
NV100503086OtherNEVADA MEDICAID
UT=========005Medicaid
WY121965100OtherWYOMING MEDICAID