Provider Demographics
NPI:1912058942
Name:UTAH CANCER SPECIALISTS PC
Entity Type:Organization
Organization Name:UTAH CANCER SPECIALISTS PC
Other - Org Name:UTAH CANCER SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:
Authorized Official - Last Name:MOYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-262-9494
Mailing Address - Street 1:1121 E 3900 S
Mailing Address - Street 2:STE C230
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1214
Mailing Address - Country:US
Mailing Address - Phone:801-262-9494
Mailing Address - Fax:801-266-2074
Practice Address - Street 1:3838 S 700 E
Practice Address - Street 2:STE 100
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-1466
Practice Address - Country:US
Practice Address - Phone:801-270-2253
Practice Address - Fax:801-267-5608
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UTAH CANCER SPECIALISTS PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-16
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5153A207RH0003X
2085R0001X, 363A00000X, 363L00000X
UT62476691704332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332900000XSuppliersNon-Pharmacy Dispensing SiteGroup - Multi-Specialty
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT4610728OtherNCPDP
UT1097950002Medicare NSC
UT4610728OtherNCPDP