Healthcare Provider Details

I. General information

NPI: 1821029869
Provider Name (Legal Business Name): PETER G LARCOM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 01/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5316 S WOODROW ST STE 200
MURRAY UT
84107-5838
US

IV. Provider business mailing address

5316 S WOODROW ST STE 200
MURRAY UT
84107-5838
US

V. Phone/Fax

Practice location:
  • Phone: 801-747-1020
  • Fax: 801-747-1023
Mailing address:
  • Phone: 801-747-1020
  • Fax: 801-747-1023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number321930-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: