Healthcare Provider Details

I. General information

NPI: 1417986209
Provider Name (Legal Business Name): UNIVERSITY EAR NOSE AND THROAT ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 04/14/2009
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

PO BOX 413035
SALT LAKE CITY UT
84141-0001
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 Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207YX0602X
TaxonomyOtolaryngic Allergy Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207YX0901X
TaxonomyOtology & Neurotology Physician
License Number
License Number State

VIII. Authorized Official

Name: JANELL I MADONNA
Title or Position: DIRECTOR OF CONTRACTING AND PE
Credential:
Phone: 801-587-6464