Healthcare Provider Details

I. General information

NPI: 1750569562
Provider Name (Legal Business Name): PARK CITY INTERNAL MEDICINE - PEDIATRICS, LC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2008
Last Update Date: 05/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1612 UTE BLVD STE 205
PARK CITY UT
84098-7500
US

IV. Provider business mailing address

1612 UTE BLVD STE 205
PARK CITY UT
84098-7500
US

V. Phone/Fax

Practice location:
  • Phone: 435-655-3309
  • Fax: 435-655-3392
Mailing address:
  • Phone: 435-655-3309
  • Fax: 435-655-3392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number5151398-1205
License Number StateUT

VIII. Authorized Official

Name: PENNY PEACOCK
Title or Position: OWNER
Credential: MD
Phone: 435-655-3309