MEDICARE: WESTERN PEAKS PHYSICIAN GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RP1001X	Pulmonary Disease Physician

General Provider Information

NPI Number	:	1134725500
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WESTERN PEAKS PHYSICIAN GROUP

Provider Business Mailing Address
First Line	:	PO BOX 58412
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84158-0412
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1219 E BROWNING AVE
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84105-2525
Country	:	US
Telephone Number	:	917-589-3056
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	AIDIN IRAVANI
Credential	:	MD
Telephone Number	:	917-589-3056

Provider Enumeration Date	:	12/10/2020
Last Update Date	:	07/22/2024

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