Healthcare Provider Details

I. General information

NPI: 1477676930
Provider Name (Legal Business Name): PHYSICIAN GROUP OF UTAH INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 03/06/2020
Certification Date: 03/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 W SOUTH JORDAN PKWY SUITE 500
SOUTH JORDAN UT
84095-3965
US

IV. Provider business mailing address

PO BOX 281415
ATLANTA GA
30384-1415
US

V. Phone/Fax

Practice location:
  • Phone: 801-984-3418
  • Fax: 801-984-3479
Mailing address:
  • Phone: 800-673-1270
  • Fax: 314-432-9683

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: ASHLEY KOCH
Title or Position: CFO
Credential:
Phone: 617-562-7070