Provider Demographics
NPI:1356637599
Name:INTERNAL MED- CARDIOLOGY- EP- DEPT OF UNIVERSITY OF UTAH
Entity Type:Organization
Organization Name:INTERNAL MED- CARDIOLOGY- EP- DEPT OF UNIVERSITY OF UTAH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:MORENO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-587-6336
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:84141-3033
Mailing Address - Country:US
Mailing Address - Phone:801-213-3800
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:84132-0100
Practice Address - Country:US
Practice Address - Phone:801-213-3800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-27
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty