Provider Demographics
NPI:1720220353
Name:DEVELOPMENTAL PEDIATRICS
Entity Type:Organization
Organization Name:DEVELOPMENTAL PEDIATRICS
Other - Org Name:U OF U DEVELOPMENTAL PEDIATRICS
Other - Org Type:Other Name
Authorized Official - Title/Position:PROVIDER ENROLLMENT SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:P
Authorized Official - Last Name:RINGWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-587-6466
Mailing Address - Street 1:PO BOX 413021
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84141-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:44 N MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1105
Practice Address - Country:US
Practice Address - Phone:801-213-3469
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-27
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral PediatricsGroup - Multi-Specialty