Provider Demographics
NPI:1558693523
Name:MARY JANE NORMAN MD A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:MARY JANE NORMAN MD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:NORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-599-5258
Mailing Address - Street 1:PO BOX 901797
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84090-1797
Mailing Address - Country:US
Mailing Address - Phone:801-599-5258
Mailing Address - Fax:801-505-0803
Practice Address - Street 1:451 BISHOP FEDERAL LN
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-2357
Practice Address - Country:US
Practice Address - Phone:801-942-0616
Practice Address - Fax:801-942-6861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-02
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT181657-1205207SG0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207SG0205XAllopathic & Osteopathic PhysiciansMedical GeneticsPh.D. Medical GeneticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000010069Medicare PIN