Healthcare Provider Details

I. General information

NPI: 1992730139
Provider Name (Legal Business Name): SUSAN L. EDWARDS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2295 FOOTHILL DR
SALT LAKE CITY UT
84109-4000
US

IV. Provider business mailing address

2295 FOOTHILL DR
SALT LAKE CITY UT
84109-4000
US

V. Phone/Fax

Practice location:
  • Phone: 801-486-3021
  • Fax: 801-485-6339
Mailing address:
  • Phone: 801-486-3021
  • Fax: 801-485-6339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1700201205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: