Healthcare Provider Details

I. General information

NPI: 1740499433
Provider Name (Legal Business Name): INTERMOUNTAIN PEDIATRIC CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 E SOUTH TEMPLE SUITE 310
SALT LAKE CITY UT
84102-1013
US

IV. Provider business mailing address

508 E SOUTH TEMPLE SUITE 310
SALT LAKE CITY UT
84102-1013
US

V. Phone/Fax

Practice location:
  • Phone: 801-355-4316
  • Fax: 801-355-6267
Mailing address:
  • Phone: 801-355-4316
  • Fax: 801-355-6267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080H0002X
TaxonomyPediatric Hospice and Palliative Medicine Physician
License Number19920633
License Number StateUT

VIII. Authorized Official

Name: MS. SUSAN HARRIS
Title or Position: OFFICE MANAGER
Credential:
Phone: 801-355-4316