Healthcare Provider Details

I. General information

NPI: 1689840209
Provider Name (Legal Business Name): PEDIATRIC ALLERGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2008
Last Update Date: 08/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MARIO CAPECCHI DR PEDIATRIC ALLERGY
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: 801-662-2100
  • Fax: 801-662-2120
Mailing address:
  • Phone: 801-587-7400
  • Fax: 801-587-7417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License Number
License Number State

VIII. Authorized Official

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