Provider Demographics
NPI:1851609564
Name:PEDIATRIC INPATIENT SERVICES RIVERTON
Entity Type:Organization
Organization Name:PEDIATRIC INPATIENT SERVICES RIVERTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER, PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:A
Authorized Official - Last Name:DONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-285-4000
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:84141-3021
Mailing Address - Country:US
Mailing Address - Phone:801-213-3800
Mailing Address - Fax:
Practice Address - Street 1:3741 W 126000 S
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065
Practice Address - Country:US
Practice Address - Phone:801-285-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-15
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty