1699796706 NPI number — UNIVERSITY PRIMARY CARE SPORTS MED

Table of content: (NPI 1699796706)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699796706 NPI number — UNIVERSITY PRIMARY CARE SPORTS MED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UNIVERSITY PRIMARY CARE SPORTS MED
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699796706
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/06/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 510004
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84151-0004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-587-6303
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
555 FOOTHILL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALT LAKE CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84112-1106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-585-5382
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MAGILL
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
K
Authorized Official Title or Position:
DEPARTMENT CHAIR
Authorized Official Telephone Number:
801-585-5382

Provider Taxonomy Codes

  • Taxonomy code: 207QS0010X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 807551900 . This is a "IDAHO MEDICAID" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: DG1456 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 100510167 . This is a "NEVADA MEDICAID" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: 123613000 . This is a "WYOMING MEDICAID" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".




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