Provider Demographics
NPI:1659488799
Name:PEDIATRIC ORTHOPEDIC ASSOCIATES
Entity Type:Organization
Organization Name:PEDIATRIC ORTHOPEDIC ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPARTMENT CHAIR
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:KENDRICK
Authorized Official - Last Name:STOTTS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-588-3900
Mailing Address - Street 1:PO BOX 58886
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84158-0886
Mailing Address - Country:US
Mailing Address - Phone:801-213-8300
Mailing Address - Fax:
Practice Address - Street 1:100 MARIO CAPECCHI DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84112-8924
Practice Address - Country:US
Practice Address - Phone:801-588-3900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric RadiologyGroup - Multi-Specialty
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Multi-Specialty
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiologyGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO22074538OtherCOLORADO MEDICAID
ID806656500OtherIDAHO MEDICAID
WY122394100OtherWYOMING MEDICIAD
UT=========004Medicaid
ID806656500OtherIDAHO MEDICAID