MEDICARE: HEALTH DIVERSIFIED - MEDICAL GROUP OF UTAH

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	207V00000X	Obstetrics & Gynecology Physician
2	1041C0700X	Clinical Social Worker
3	225100000X	Physical Therapist
4	363L00000X	Nurse Practitioner
5	251B00000X	Case Management Agency
6	207R00000X	Internal Medicine Physician
7	363A00000X	Physician Assistant
8	103TC1900X	Counseling Psychologist
9	207SG0201X	Clinical Genetics (M.D.) Physician
10	208000000X	Pediatrics Physician
11	207P00000X	Emergency Medicine Physician
12	207Q00000X	Family Medicine Physician
13	133V00000X	Registered Dietitian
14	261QC1800X	Corporate Health Clinic/Center
15	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1508518085
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEALTH DIVERSIFIED - MEDICAL GROUP OF UTAH

Provider Business Mailing Address
First Line	:	5986 S TOLCATE WOODS LN
Second Line	:
City	:	HOLLADAY
State	:	UT
Zip	:	84121-1536
Country	:	US
Telephone Number	:	801-682-6817
Fax Number	:	385-213-0356

Provider Business Practice Location Address
First Line	:	4544 S HOLLADAY BLVD
Second Line	:
City	:	HOLLADAY
State	:	UT
Zip	:	84117-4404
Country	:	US
Telephone Number	:	801-682-6817
Fax Number	:	385-213-0356

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	MRS. ANN SMITH
Credential	:
Telephone Number	:	801-682-6817

Provider Enumeration Date	:	01/25/2022
Last Update Date	:	03/06/2026

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