Provider Demographics
NPI:1487683462
Name:WEST JORDAN MEDICAL CENTER PC
Entity Type:Organization
Organization Name:WEST JORDAN MEDICAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:ONEIDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-567-5990
Mailing Address - Street 1:3570 W 9000 S
Mailing Address - Street 2:STE 200
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-8869
Mailing Address - Country:US
Mailing Address - Phone:801-566-9211
Mailing Address - Fax:801-566-5667
Practice Address - Street 1:3570 W 9000 S STE 200
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-8875
Practice Address - Country:US
Practice Address - Phone:801-566-9211
Practice Address - Fax:801-566-5667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT529903072047Medicaid
UT000055265Medicare ID - Type Unspecified