Provider Demographics
NPI:1629022827
Name:PEDIATRIC GENETICS DEPARTMENT OF UNIVERSITY OF UTAH
Entity Type:Organization
Organization Name:PEDIATRIC GENETICS DEPARTMENT OF UNIVERSITY OF UTAH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIR
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:B
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-587-7400
Mailing Address - Street 1:295 CHIPETA WAY
Mailing Address - Street 2:PEDS ADMIN
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1220
Mailing Address - Country:US
Mailing Address - Phone:801-587-7400
Mailing Address - Fax:801-587-7417
Practice Address - Street 1:50 N MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0001
Practice Address - Country:US
Practice Address - Phone:801-581-8943
Practice Address - Fax:801-585-7252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)Group - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100507116Medicaid
ID807154000Medicaid
WY121238900Medicaid
UT=========001Medicaid
NV100507116Medicaid