MEDICARE: PEACHTREE FAMILY MEDICINE 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	207Q00000X	Family Medicine Physician	5916429-1205	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1679608582
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEACHTREE FAMILY MEDICINE PC

Provider Business Mailing Address
First Line	:	169 N GATEWAY DR
Second Line	:	170
City	:	PROVIDENCE
State	:	UT
Zip	:	84332-9855
Country	:	US
Telephone Number	:	435-752-5553
Fax Number	:	435-755-5043

Provider Business Practice Location Address
First Line	:	565 W 465 N STE 130
Second Line	:
City	:	PROVIDENCE
State	:	UT
Zip	:	84332-4802
Country	:	US
Telephone Number	:	435-752-5553
Fax Number	:	435-755-5043

Authorized Official
Title or Position	:	MD
Name	:	VERA B CARLSON
Credential	:	MD
Telephone Number	:	435-752-5553

Provider Enumeration Date	:	02/22/2007
Last Update Date	:	11/06/2024

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Directions to “PEACHTREE FAMILY MEDICINE PC ” Practice Location

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