Healthcare Provider Details

I. General information

NPI: 1285703678
Provider Name (Legal Business Name): PEDIATRIC ENDOCRINOLOGY DEPARTMENT OF UNIVERSITY OF UTAH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 09/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N MEDICAL DR PEDS ENDOCRINOLOGY
SALT LAKE CITY UT
84113-1103
US

IV. Provider business mailing address

295 CHIPETA WAY U OF U SOM DEPT OF PEDIATRICS
SALT LAKE CITY UT
84108-1220
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-7761
  • Fax: 801-587-3997
Mailing address:
  • Phone: 801-587-7400
  • Fax: 801-587-7417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier100507114
Identifier TypeMEDICAID
Identifier StateNV
Identifier Issuer
# 2
Identifier121232000
Identifier TypeMEDICAID
Identifier StateWY
Identifier Issuer
# 3
Identifier807164000
Identifier TypeMEDICAID
Identifier StateID
Identifier Issuer

VIII. Authorized Official

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