Provider Demographics
NPI:1760776223
Name:PEDIATRIC PM AND R
Entity Type:Organization
Organization Name:PEDIATRIC PM AND R
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIR
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIE
Authorized Official - Middle Name:P
Authorized Official - Last Name:ELOVIC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-662-4949
Mailing Address - Street 1:PO BOX 413032
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84141-3032
Mailing Address - Country:US
Mailing Address - Phone:801-213-3900
Mailing Address - Fax:801-585-3655
Practice Address - Street 1:100 MARIO CAPECCHI DR
Practice Address - Street 2:ROOM 4400
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1103
Practice Address - Country:US
Practice Address - Phone:801-662-4949
Practice Address - Fax:801-662-4931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-01
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT72775361205208100000X, 2081P0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPediatric Rehabilitation MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty