Provider Demographics
NPI:1477676930
Name:PHYSICIAN GROUP OF UTAH INC
Entity Type:Organization
Organization Name:PHYSICIAN GROUP OF UTAH INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-562-7070
Mailing Address - Street 1:PO BOX 281415
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-1415
Mailing Address - Country:US
Mailing Address - Phone:800-673-1270
Mailing Address - Fax:314-432-9683
Practice Address - Street 1:406 W SOUTH JORDAN PKWY
Practice Address - Street 2:SUITE 500
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-3965
Practice Address - Country:US
Practice Address - Phone:801-984-3418
Practice Address - Fax:801-984-3479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1477676930Medicaid
UT1477676930Medicaid
WYW22635Medicare PIN