Provider Demographics
NPI:1669927695
Name:PEDIATRIC GENETICS DEPARTMENT OF UNIVERSITY OF UTAH
Entity type:Organization
Organization Name:PEDIATRIC GENETICS DEPARTMENT OF UNIVERSITY OF UTAH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPARTMENT CHAIR
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:B
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-587-7415
Mailing Address - Street 1:DEPARTMENT OF PEDIATRICS
Mailing Address - Street 2:50 NORTH MARIO CAPECCHI DRIVE
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84132-0001
Mailing Address - Country:US
Mailing Address - Phone:801-581-8943
Mailing Address - Fax:801-585-7252
Practice Address - Street 1:DEPARTMENT OF PEDIATRICS
Practice Address - Street 2:50 NORTH MARIO CAPECCHI DRIVE
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0001
Practice Address - Country:US
Practice Address - Phone:801-581-8943
Practice Address - Fax:801-585-7252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-19
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9858866-3602170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes170300000XOther Service ProvidersGenetic Counselor, MSGroup - Single Specialty