Healthcare Provider Details

I. General information

NPI: 1588714091
Provider Name (Legal Business Name): MICHAEL D KILLPACK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 01/15/2021
Certification Date: 01/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 S 1100 E STE 310
SALT LAKE CITY UT
84102-1500
US

IV. Provider business mailing address

24 S 1100 E STE 310
SALT LAKE CITY UT
84102-1500
US

V. Phone/Fax

Practice location:
  • Phone: 801-328-1260
  • Fax: 801-350-4361
Mailing address:
  • Phone: 801-328-1260
  • Fax: 801-350-4361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number6108381-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number6108381-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: