MEDICARE: WASATCH VASCULAR CENTER ASC LLC

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	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1184245169
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WASATCH VASCULAR CENTER ASC LLC

Provider Business Mailing Address
First Line	:	40 VALLEY STREAM PKWY STE 100
Second Line	:
City	:	MALVERN
State	:	PA
Zip	:	19355-1407
Country	:	US
Telephone Number	:	610-644-8900
Fax Number	:	484-924-0053

Provider Business Practice Location Address
First Line	:	3702 S STATE ST
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84115-5078
Country	:	US
Telephone Number	:	801-281-0027
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	GREGG MILLER
Credential	:	MD
Telephone Number	:	717-515-4048

Provider Enumeration Date	:	05/01/2020
Last Update Date	:	03/13/2025

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