Healthcare Provider Details

I. General information

NPI: 1669927695
Provider Name (Legal Business Name): PEDIATRIC GENETICS DEPARTMENT OF UNIVERSITY OF UTAH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2016
Last Update Date: 08/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

DEPARTMENT OF PEDIATRICS 50 NORTH MARIO CAPECCHI DRIVE
SALT LAKE CITY UT
84132-0001
US

IV. Provider business mailing address

DEPARTMENT OF PEDIATRICS 50 NORTH MARIO CAPECCHI DRIVE
SALT LAKE CITY UT
84132-0001
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-8943
  • Fax: 801-585-7252
Mailing address:
  • Phone: 801-581-8943
  • Fax: 801-585-7252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License Number9858866-3602
License Number StateUT

VIII. Authorized Official

Name: DR. EDWARD B. CLARK
Title or Position: DEPARTMENT CHAIR
Credential:
Phone: 801-587-7415