1003306473 NPI number — PETER MICHAEL SUNDWALL

Table of content: PETER MICHAEL SUNDWALL (NPI 1003306473)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003306473 NPI number — PETER MICHAEL SUNDWALL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUNDWALL
Provider First Name:
PETER
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

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:
1003306473
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/25/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10290 N NORTH COUNTY BLVD STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HIGHLAND
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84003-8973
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-899-3391
Provider Business Mailing Address Fax Number:
801-685-3266

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10290 N. NORTH COUNTY BLVD. STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HIGHLAND
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84003-8400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-625-6000
Provider Business Practice Location Address Fax Number:
208-625-6001
Provider Enumeration Date:
05/11/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  12158239-1205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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