MEDICARE: J. DAYNE PETERSEN M.D., PC

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	261QM2500X	Medical Specialty Clinic/Center	83185641205	UT

General Provider Information

NPI Number	:	1346597507
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	J. DAYNE PETERSEN M.D., PC

Provider Business Mailing Address
First Line	:	5353 S 960 E
Second Line	:	#150
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-3569
Country	:	US
Telephone Number	:	801-261-5791
Fax Number	:	801-747-7740

Provider Business Practice Location Address
First Line	:	5353 S 960 E
Second Line	:	#150
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-3569
Country	:	US
Telephone Number	:	801-261-5791
Fax Number	:	801-747-7740

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JASON DAYNE PETERSEN
Credential	:	M.D.
Telephone Number	:	801-971-8684

Provider Enumeration Date	:	08/07/2012
Last Update Date	:	08/30/2012

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