Healthcare Provider Details

I. General information

NPI: 1770841785
Provider Name (Legal Business Name): UNIVERSITY OF UTAH PEDIATRIC CARDIOLOGY ELECTROPHYSIOLOGY SVCS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2012
Last Update Date: 05/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MARIO CAPECCHI DR
SALT LAKE CITY UT
84113-1103
US

IV. Provider business mailing address

295 CHIPETA WAY
SALT LAKE CITY UT
84108-1287
US

V. Phone/Fax

Practice location:
  • Phone: 801-662-5400
  • Fax: 801-662-5404
Mailing address:
  • Phone: 801-587-7400
  • Fax: 801-587-7417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204R00000X
TaxonomyElectrodiagnostic Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. EDWARD B CLARK
Title or Position: CHAIR
Credential: MD
Phone: 801-587-7400