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General NPI Number Information
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NPI Number | 1750569562
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Entity Type | Organization
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Legal Business Name | PARK CITY INTERNAL MEDICINE - PEDIATRICS, LC
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Dates
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Enumeration Date | 02/04/2008
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Last Update Date | 05/18/2011
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Provider Practice Location Address
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Address Line | 1612 UTE BLVD STE 205
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City | PARK CITY
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State | UT
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Zip | 84098-7500
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Country | US
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Telephone | 435-655-3309
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Fax | 435-655-3392
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Provider Business Mailing Address
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Address Line | 1612 UTE BLVD STE 205
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City | PARK CITY
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State | UT
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Zip | 84098-7500
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Country | US
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Telephone | 435-655-3309
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Fax | 435-655-3392
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Authorized Official
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Title or Position | OWNER
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Name | PENNY PEACOCK
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Credential | MD
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Telephone | 435-655-3309
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number | 5151398-1205
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License Number State | UT
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