Healthcare Provider Details

I. General information

NPI: 1629022827
Provider Name (Legal Business Name): PEDIATRIC GENETICS DEPARTMENT OF UNIVERSITY OF UTAH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 09/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 N MEDICAL DR
SALT LAKE CITY UT
84132-0001
US

IV. Provider business mailing address

295 CHIPETA WAY PEDS ADMIN
SALT LAKE CITY UT
84108-1220
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-8943
  • Fax: 801-585-7252
Mailing address:
  • Phone: 801-587-7400
  • Fax: 801-587-7417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

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