Healthcare Provider Details

I. General information

NPI: 1164724860
Provider Name (Legal Business Name): UTAH CENTER FOR REPRODUCTIVE MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2010
Last Update Date: 12/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 ARAPEEN DR 205
SALT LAKE CITY UT
84108-1223
US

IV. Provider business mailing address

PO BOX 410475
SALT LAKE CITY UT
84141-3475
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-2121
  • Fax:
Mailing address:
  • Phone: 801-213-3800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number
License Number State

VIII. Authorized Official

Name: CHARLES MATTHEW PETERSON
Title or Position: DEPARTMENT CHAIR
Credential: MD
Phone: 801-581-2121