Healthcare Provider Details

I. General information

NPI: 1033671540
Provider Name (Legal Business Name): PHYSICIAN GROUP OF UTAH INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2019
Last Update Date: 04/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1580 W ANTELOPE DR STE 290
LAYTON UT
84041-1179
US

IV. Provider business mailing address

PO BOX 281415
ATLANTA GA
30384-1415
US

V. Phone/Fax

Practice location:
  • Phone: 801-776-0880
  • Fax: 801-773-7399
Mailing address:
  • Phone: 800-673-1270
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: TYLER K WILKO
Title or Position: CEO
Credential:
Phone: 801-984-3293