Provider Demographics
NPI:1609896216
Name:SALT LAKE ENDOSCOPY CENTER
Entity Type:Organization
Organization Name:SALT LAKE ENDOSCOPY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEWART
Authorized Official - Middle Name:L
Authorized Official - Last Name:ELLINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:DR
Authorized Official - Phone:801-364-5767
Mailing Address - Street 1:24 SOUTH 1100 EAST #103
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102
Mailing Address - Country:US
Mailing Address - Phone:801-355-2987
Mailing Address - Fax:801-531-9704
Practice Address - Street 1:24 S 1100 E STE 103
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1592
Practice Address - Country:US
Practice Address - Phone:801-355-2987
Practice Address - Fax:801-531-9704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2006-ASF-332261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========009Medicaid