Provider Demographics
NPI:1659540359
Name:UTAH PODIATRY GROUP, P.C.
Entity Type:Organization
Organization Name:UTAH PODIATRY GROUP, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:A
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:801-505-5277
Mailing Address - Street 1:PO BOX 30015
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84130-0015
Mailing Address - Country:US
Mailing Address - Phone:801-451-6060
Mailing Address - Fax:801-797-9154
Practice Address - Street 1:82 S 1100 E
Practice Address - Street 2:STE 301
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102
Practice Address - Country:US
Practice Address - Phone:801-505-5277
Practice Address - Fax:801-505-5280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-27
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT106339-0501332B00000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000010533Medicare PIN
UT000012152Medicare PIN
UT000057551Medicare PIN
UT000000091Medicare PIN
UT000011861Medicare PIN
UT000011733Medicare PIN
UT6152070001Medicare NSC