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General NPI Number Information
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NPI Number | 1740499433
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Entity Type | Organization
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Legal Business Name | INTERMOUNTAIN PEDIATRIC CLINIC
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Dates
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Enumeration Date | 05/21/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 508 E SOUTH TEMPLE SUITE 310
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City | SALT LAKE CITY
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State | UT
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Zip | 84102-1013
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Country | US
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Telephone | 801-355-4316
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Fax | 801-355-6267
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Provider Business Mailing Address
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Address Line | 508 E SOUTH TEMPLE SUITE 310
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City | SALT LAKE CITY
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State | UT
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Zip | 84102-1013
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Country | US
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Telephone | 801-355-4316
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Fax | 801-355-6267
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MS. SUSAN HARRIS
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Credential |
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Telephone | 801-355-4316
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2080H0002X
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Taxonomy Name | Pediatric Hospice and Palliative Medicine Physician
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License Number | 19920633
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License Number State | UT
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