Provider Demographics
NPI:1417981002
Name:FAATZ, JILL BATEMAN (MD)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:BATEMAN
Last Name:FAATZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-714-5000
Mailing Address - Fax:801-714-5511
Practice Address - Street 1:1975 N STATE ST
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-2028
Practice Address - Country:US
Practice Address - Phone:801-714-5000
Practice Address - Fax:801-714-5511
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5682434-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT122606Medicare UPIN
UT000063237Medicare PIN