Provider Demographics
NPI:1659012292
Name:PLASTIC SURGERY INSTITUTE OF UTAH
Entity Type:Organization
Organization Name:PLASTIC SURGERY INSTITUTE OF UTAH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:KIRK
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-685-2730
Mailing Address - Street 1:7535 S UNION PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-3043
Mailing Address - Country:US
Mailing Address - Phone:801-859-9004
Mailing Address - Fax:877-595-1086
Practice Address - Street 1:7535 S UNION PARK AVE
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-3043
Practice Address - Country:US
Practice Address - Phone:801-859-9004
Practice Address - Fax:877-595-1086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-06
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center