Healthcare Provider Details

I. General information

NPI: 1003825928
Provider Name (Legal Business Name): UNIVERSITY OF UTAH PEDIATRIC PLASTIC SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2006
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 58049
SALT LAKE CITY UT
84158-0049
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-2121
  • Fax:
Mailing address:
  • Phone: 801-581-7073
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery 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