Provider Demographics
NPI:1790794014
Name:UNIVERSITY CARDIOTHORACIC-PEDIATRIC
Entity Type:Organization
Organization Name:UNIVERSITY CARDIOTHORACIC-PEDIATRIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CONTRACTING AND PE
Authorized Official - Prefix:
Authorized Official - First Name:JANELL
Authorized Official - Middle Name:I
Authorized Official - Last Name:MADONNA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-587-6464
Mailing Address - Street 1:PO BOX 58049
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84158-0049
Mailing Address - Country:US
Mailing Address - Phone:801-588-3345
Mailing Address - Fax:
Practice Address - Street 1:100 MARIO CAPECCHI DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1103
Practice Address - Country:US
Practice Address - Phone:801-588-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2009-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric SurgeryGroup - Multi-Specialty
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000055342Medicare ID - Type Unspecified