MEDICARE: UTAH CENTER FOR REPRODUCTIVE MEDICINE

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	207VE0102X	Reproductive Endocrinology Physician

General Provider Information

NPI Number	:	1164724860
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UTAH CENTER FOR REPRODUCTIVE MEDICINE

Provider Business Mailing Address
First Line	:	PO BOX 410475
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84141-3475
Country	:	US
Telephone Number	:	801-213-3800
Fax Number	:

Provider Business Practice Location Address
First Line	:	675 ARAPEEN DR
Second Line	:	205
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-1223
Country	:	US
Telephone Number	:	801-581-2121
Fax Number	:

Authorized Official
Title or Position	:	DEPARTMENT CHAIR
Name	:	CHARLES MATTHEW PETERSON
Credential	:	MD
Telephone Number	:	801-581-2121

Provider Enumeration Date	:	12/01/2010
Last Update Date	:	12/01/2010

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