Healthcare Provider Details

I. General information

NPI: 1467414581
Provider Name (Legal Business Name): PETER P TAILLAC MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 07/16/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIVERSITY OF UTAH DIVISION OF EMERGENCY MEDICINE 30 NORTH 1900 EAST ROOM 1C026
SALT LAKE CITY UT
84132-0001
US

IV. Provider business mailing address

3439 CANYON COVE DR
HOLLADAY UT
84121-6335
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-2417
  • Fax:
Mailing address:
  • Phone: 801-272-7606
  • Fax: 801-272-5399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number279025-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number279025-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: