Provider Demographics
NPI:1437116266
Name:PARK CITY PODIATRY LLC
Entity Type:Organization
Organization Name:PARK CITY PODIATRY LLC
Other - Org Name:SALT LAKE CITY PODIATRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:E
Authorized Official - Last Name:MORITZ
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:801-269-9939
Mailing Address - Street 1:PO BOX 404
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84065-0404
Mailing Address - Country:US
Mailing Address - Phone:801-619-2168
Mailing Address - Fax:877-428-7520
Practice Address - Street 1:1220 E 3900 S STE 4D
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1383
Practice Address - Country:US
Practice Address - Phone:801-269-9939
Practice Address - Fax:801-269-9949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1245297688Medicaid
UT1245297688Medicaid
UT4552360002Medicare NSC