Provider Demographics
NPI:1689906976
Name:PREMIER PLASTIC SURGERY GROUP OF UTAH
Entity Type:Organization
Organization Name:PREMIER PLASTIC SURGERY GROUP OF UTAH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-571-2020
Mailing Address - Street 1:11762 S STATE ST STE 220
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-7156
Mailing Address - Country:US
Mailing Address - Phone:801-571-2020
Mailing Address - Fax:801-571-6899
Practice Address - Street 1:11762 S STATE ST STE 220
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-7156
Practice Address - Country:US
Practice Address - Phone:801-571-2020
Practice Address - Fax:801-571-6899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-11
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528276851028Medicaid
UT529316986001Medicaid
UT000057752Medicare PIN
UT529316986001Medicaid
UT528276851028Medicaid
UTUT03528Medicare PIN