Healthcare Provider Details

I. General information

NPI: 1215061593
Provider Name (Legal Business Name): UNIVERSITY OF UTAH DEPT OF OBGYN UROGYNECOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 07/26/2007
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 58859
SALT LAKE CITY UT
84158-0859
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-2719
  • Fax:
Mailing address:
  • Phone: 801-213-3800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: ERICKA LINDLEY
Title or Position: CLINICAL ADMIN MANAGER
Credential:
Phone: 801-581-3118