Provider Demographics
NPI:1457393084
Name:MATERNAL FETAL SERVICES OF UTAH LLC
Entity Type:Organization
Organization Name:MATERNAL FETAL SERVICES OF UTAH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:KANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-568-5999
Mailing Address - Street 1:1140 E 3900 S
Mailing Address - Street 2:SUITE 390
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1228
Mailing Address - Country:US
Mailing Address - Phone:801-743-4700
Mailing Address - Fax:801-743-4705
Practice Address - Street 1:1140 E 3900 S
Practice Address - Street 2:SUITE 390
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1228
Practice Address - Country:US
Practice Address - Phone:801-743-4700
Practice Address - Fax:801-743-4705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO60271256Medicaid
OK200134000AMedicaid
NV1457393084Medicaid
ID807101900Medicaid
WY121073400Medicaid
VA1457393084Medicaid
ID1366723Medicare PIN
ID807101900Medicaid
NV1457393084Medicaid
DP9915Medicare PIN