Healthcare Provider Details

I. General information

NPI: 1417983776
Provider Name (Legal Business Name): UNIVERSITY OF UTAH OB DIAGNOSTIC CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 06/30/2008
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: 801-585-5172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number
License Number State

VIII. Authorized Official

Name: C. MATTHEW PETERSON
Title or Position: DEPARTMENT CHAIR
Credential: MD
Phone: 801-581-2719