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General NPI Number Information
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NPI Number | 1689461774
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Entity Type | Organization
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Legal Business Name | PRESIDIUM MEDICAL GROUP PLLC
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Dates
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Enumeration Date | 04/22/2025
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Last Update Date | 04/22/2025
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Provider Practice Location Address
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Address Line | 32 E EXCHANGE PL FL 6
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City | SALT LAKE CITY
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State | UT
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Zip | 84111-2704
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Country | US
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Telephone | 619-738-5566
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Fax |
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Provider Business Mailing Address
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Address Line | 32 E EXCHANGE PL FL 6
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City | SALT LAKE CITY
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State | UT
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Zip | 84111-2704
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Country | US
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Telephone | 619-738-5566
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Fax | 619-566-0202
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Authorized Official
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Title or Position | OWNER
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Name | DR. ASHKAN HAYATDAVOUDI
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Credential | MD
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Telephone | 619-738-5566
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QA0505X
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Taxonomy Name | Adult Medicine Physician
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License Number |
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License Number State |
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