Healthcare Provider Details

I. General information

NPI: 1154883668
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

5979 S 300 E
MURRAY UT
84107-7364
US

IV. Provider business mailing address

PO BOX 281415
ATLANTA GA
30384-1415
US

V. Phone/Fax

Practice location:
  • Phone: 801-263-2370
  • Fax: 801-265-1200
Mailing address:
  • Phone: 800-673-1270
  • Fax: 314-432-9683

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

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