Provider Demographics
NPI:1659991438
Name:UTAH PODIATRY GROUP PC
Entity Type:Organization
Organization Name:UTAH PODIATRY GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS & CREDENTIAL
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-505-0821
Mailing Address - Street 1:PO BOX 30015 DEPT 380
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 1:3435 E PONY EXPRESS PKWY STE 140
Practice Address - Street 2:
Practice Address - City:EAGLE MOUNTAIN
Practice Address - State:UT
Practice Address - Zip Code:84005-5548
Practice Address - Country:US
Practice Address - Phone:801-893-8811
Practice Address - Fax:801-789-2046
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UTAH PODIATRY GROUP PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-04-21
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty