Provider Demographics
NPI:1245524651
Name:PEDIATRIC EMERGENCY SEDATION SERVICE
Entity type:Organization
Organization Name:PEDIATRIC EMERGENCY SEDATION SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACTING DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANELL
Authorized Official - Middle Name:
Authorized Official - Last Name:MADONNA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-587-6464
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:801-213-3900
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:801-662-1234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-02
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT31763412052080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency MedicineGroup - Multi-Specialty