Provider Demographics
NPI:1861502254
Name:PEDIATRIC RADIOLOGY, P.C.
Entity Type:Organization
Organization Name:PEDIATRIC RADIOLOGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:S
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-487-0451
Mailing Address - Street 1:869 E 4500 S
Mailing Address - Street 2:PMB 511
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-3049
Mailing Address - Country:US
Mailing Address - Phone:801-487-0451
Mailing Address - Fax:801-487-2467
Practice Address - Street 1:100 N MEDICAL 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:801-662-1900
Practice Address - Fax:801-662-1810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========OtherTAX ID NUMBER