Provider Demographics
NPI:1740499433
Name:INTERMOUNTAIN PEDIATRIC CLINIC
Entity type:Organization
Organization Name:INTERMOUNTAIN PEDIATRIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-355-4316
Mailing Address - Street 1:508 E SOUTH TEMPLE
Mailing Address - Street 2:SUITE 310
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1013
Mailing Address - Country:US
Mailing Address - Phone:801-355-4316
Mailing Address - Fax:801-355-6267
Practice Address - Street 1:508 E SOUTH TEMPLE
Practice Address - Street 2:SUITE 310
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1013
Practice Address - Country:US
Practice Address - Phone:801-355-4316
Practice Address - Fax:801-355-6267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT199206332080H0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080H0002XAllopathic & Osteopathic PhysiciansPediatricsHospice and Palliative MedicineGroup - Single Specialty