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General NPI Number Information
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NPI Number | 1154612117
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Entity Type | Individual
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Provider Name | DANA BOUCEK
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Gender | Female
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Dates
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Enumeration Date | 04/26/2011
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Last Update Date | 10/28/2021
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Provider Practice Location Address
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Address Line | 100 NORTH MARIO CAPECCHI DR. PRIMARY CHILDREN'S
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City | SALT LAKE CITY
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State | UT
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Zip | 84113
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Country | US
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Telephone | 801-662-5700
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Fax |
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Provider Business Mailing Address
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Address Line | 3601 MARKET ST UNIT 1713
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City | PHILADELPHIA
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State | PA
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Zip | 19104-5914
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Country | US
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Telephone | 303-746-7692
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2080P0202X
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Taxonomy Name | Pediatric Cardiology Physician
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License Number | MD460722
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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