Healthcare Provider Details

I. General information

NPI: 1053594861
Provider Name (Legal Business Name): PETER V SUNDWALL MD PCA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2007
Last Update Date: 03/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4815 CENTER ST
MURRAY UT
84107-4814
US

IV. Provider business mailing address

4815 CENTER ST
MURRAY UT
84107-4814
US

V. Phone/Fax

Practice location:
  • Phone: 801-262-2443
  • Fax: 801-262-8869
Mailing address:
  • Phone: 801-262-2443
  • Fax: 801-262-8869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1498878905
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1498871205
License Number StateUT

VIII. Authorized Official

Name: PETER V SUNDWALL
Title or Position: OWNER
Credential: MD PCA
Phone: 801-262-2443