Provider Demographics
NPI:1679528715
Name:DEPARTMENT OF PEDIATRICS UNIVERSITY OF UTAH
Entity Type:Organization
Organization Name:DEPARTMENT OF PEDIATRICS UNIVERSITY OF UTAH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIR
Authorized Official - Prefix:
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 1:100 N MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1103
Practice Address - Country:US
Practice Address - Phone:801-588-2000
Practice Address - Fax:801-587-7417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX176668501Medicaid
FL911948500Medicaid
WA7038870Medicaid
ID806902200Medicaid
ID003057700Medicaid
IN200426530AMedicaid
CO94001963Medicaid
NV100500257Medicaid
OK200020440AMedicaid
NMG0749Medicaid
CO94001963Medicaid
IN200426530AMedicaid
NMG0749Medicaid
WA7038870Medicaid