Provider Demographics
NPI:1679608582
Name:PEACHTREE FAMILY MEDICINE PC
Entity Type:Organization
Organization Name:PEACHTREE FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:VERA
Authorized Official - Middle Name:B
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-752-5553
Mailing Address - Street 1:169 N GATEWAY DR
Mailing Address - Street 2:170
Mailing Address - City:PROVIDENCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332-9855
Mailing Address - Country:US
Mailing Address - Phone:435-752-5553
Mailing Address - Fax:435-755-5043
Practice Address - Street 1:565 W 465 N STE 130
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:UT
Practice Address - Zip Code:84332-4802
Practice Address - Country:US
Practice Address - Phone:435-752-5553
Practice Address - Fax:435-755-5043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5916429-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT225939539001Medicaid
UT225939539001Medicaid
UTI23766Medicare UPIN