Healthcare Provider Details

I. General information

NPI: 1659488799
Provider Name (Legal Business Name): PEDIATRIC ORTHOPEDIC ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 10/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MARIO CAPECCHI DR
SALT LAKE CITY UT
84112-8924
US

IV. Provider business mailing address

PO BOX 58886
SALT LAKE CITY UT
84158-0886
US

V. Phone/Fax

Practice location:
  • Phone: 801-588-3900
  • Fax:
Mailing address:
  • Phone: 801-213-8300
  • 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 Code2085N0700X
TaxonomyNeuroradiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: ALAN KENDRICK STOTTS
Title or Position: DEPARTMENT CHAIR
Credential: MD
Phone: 801-588-3900