Healthcare Provider Details

I. General information

NPI: 1669918769
Provider Name (Legal Business Name): UNIVERSITY OF UTAH PEDIATRIC SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2017
Last Update Date: 05/21/2020
Certification Date: 05/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1645 PANCHERI DR
IDAHO FALLS ID
83402-3169
US

IV. Provider business mailing address

PO BOX 841450
LOS ANGELES CA
90084-1450
US

V. Phone/Fax

Practice location:
  • Phone: 208-227-1460
  • Fax:
Mailing address:
  • Phone: 801-213-3900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number
License Number State

VIII. Authorized Official

Name: EDWARD CLARK
Title or Position: DEPARTMENT CHAIR
Credential: MD
Phone: 801-587-6336