Provider Demographics
NPI:1750569562
Name:PARK CITY INTERNAL MEDICINE - PEDIATRICS, LC
Entity type:Organization
Organization Name:PARK CITY INTERNAL MEDICINE - PEDIATRICS, LC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:PEACOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-655-3309
Mailing Address - Street 1:1612 UTE BLVD
Mailing Address - Street 2:STE 205
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-7500
Mailing Address - Country:US
Mailing Address - Phone:435-655-3309
Mailing Address - Fax:435-655-3392
Practice Address - Street 1:1612 UTE BLVD
Practice Address - Street 2:STE 205
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-7500
Practice Address - Country:US
Practice Address - Phone:435-655-3309
Practice Address - Fax:435-655-3392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-04
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5151398-1205261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========001Medicaid
UT000057540Medicare PIN