MEDICARE: UTAH PODIATRIC PHYSICIANS AND SURGEONS GROUP LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213E00000X	Podiatrist	7899779-0501	UT
2	213EP1101X	Primary Podiatric Medicine Podiatrist	7899779-0501	UT
3	213ES0103X	Foot & Ankle Surgery Podiatrist	7899779-0501	UT

General Provider Information

NPI Number	:	1912433426
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UTAH PODIATRIC PHYSICIANS AND SURGEONS GROUP LLC

Provider Business Mailing Address
First Line	:	144 S 700 E
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-1357
Country	:	US
Telephone Number	:	801-532-1822
Fax Number	:	801-532-7544

Provider Business Practice Location Address
First Line	:	5455 W 11000 N
Second Line	:	#203
City	:	HIGHLAND
State	:	UT
Zip	:	84003-8800
Country	:	US
Telephone Number	:	801-699-0530
Fax Number	:	801-763-9225

Authorized Official
Title or Position	:	CHAIRMAN
Name	:	DANIEL L PREECE
Credential	:	DPM
Telephone Number	:	801-532-1822

Provider Enumeration Date	:	05/03/2017
Last Update Date	:	05/03/2017

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