Provider Demographics
NPI:1558439117
Name:WESTSIDE MEDICAL PC
Entity Type:Organization
Organization Name:WESTSIDE MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SEPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-774-8888
Mailing Address - Street 1:1477 NORTH 2000 WEST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:UT
Mailing Address - Zip Code:84015-8213
Mailing Address - Country:US
Mailing Address - Phone:801-774-8888
Mailing Address - Fax:801-825-8519
Practice Address - Street 1:1477 NORTH 2000 WEST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:UT
Practice Address - Zip Code:84015-8213
Practice Address - Country:US
Practice Address - Phone:801-774-8888
Practice Address - Fax:801-825-8519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000055196Medicare ID - Type Unspecified