Provider Demographics
NPI:1790906204
Name:EAR, NOSE & THROAT SURGERY CENTER OF UTAH LLC
Entity Type:Organization
Organization Name:EAR, NOSE & THROAT SURGERY CENTER OF UTAH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MGR
Authorized Official - Prefix:
Authorized Official - First Name:EVON
Authorized Official - Middle Name:
Authorized Official - Last Name:PEFAUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-328-2522
Mailing Address - Street 1:22 S 900 E STE 2
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1307
Mailing Address - Country:US
Mailing Address - Phone:801-328-2522
Mailing Address - Fax:
Practice Address - Street 1:22 S 900 E STE 2
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1307
Practice Address - Country:US
Practice Address - Phone:801-328-2522
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT20042178261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========001Medicaid