MEDICARE: NOVACEL

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	261QP1100X	Podiatric Clinic/Center
2	213ES0103X	Foot & Ankle Surgery Podiatrist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1790243111	OTHER	UT	NPI

General Provider Information

NPI Number	:	1790243111
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NOVACEL

Provider Business Mailing Address
First Line	:	4624 S HOLLADAY BLVD STE 201
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-7168
Country	:	US
Telephone Number	:	801-438-8280
Fax Number	:	801-438-8747

Provider Business Practice Location Address
First Line	:	4624 S HOLLADAY BLVD STE 201
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-7168
Country	:	US
Telephone Number	:	18-266-3113
Fax Number	:	801-266-5633

Authorized Official
Title or Position	:	BILLING DIRECTOR
Name	:	MARIANA ANDERSON-OMINSKI
Credential	:
Telephone Number	:	801-888-1140

Provider Enumeration Date	:	03/05/2019
Last Update Date	:	08/16/2019

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Directions to “NOVACEL ” Practice Location

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