Provider Demographics
NPI:1528416047
Name:UNIVERSITY OF UTAH PEDIATRIC SERVICES
Entity Type:Organization
Organization Name:UNIVERSITY OF UTAH PEDIATRIC SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPARTMENT CHAIR
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-587-6336
Mailing Address - Street 1:PO BOX 413021
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84141-3021
Mailing Address - Country:US
Mailing Address - Phone:801-213-3900
Mailing Address - Fax:
Practice Address - Street 1:100 N MARIO CAPECCHI DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1103
Practice Address - Country:US
Practice Address - Phone:801-587-6336
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY OF UTAH PEDIATRIC SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-05-25
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty