Provider Demographics
NPI:1689840209
Name:PEDIATRIC ALLERGY
Entity Type:Organization
Organization Name:PEDIATRIC ALLERGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRPERSON
Authorized Official - Prefix:DR
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:U OF U SOM DEPT OF PEDIATRICS
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 MARIO CAPECCHI DR
Practice Address - Street 2:PEDIATRIC ALLERGY
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1103
Practice Address - Country:US
Practice Address - Phone:801-662-2100
Practice Address - Fax:801-662-2120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-03
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/ImmunologyGroup - Multi-Specialty