1457393084 NPI number — MATERNAL FETAL SERVICES OF UTAH LLC

Table of content: (NPI 1457393084)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457393084 NPI number — MATERNAL FETAL SERVICES OF UTAH LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MATERNAL FETAL SERVICES OF UTAH LLC
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:
1457393084
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/20/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1140 E 3900 S
Provider Second Line Business Mailing Address:
SUITE 390
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84124-1228
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-743-4700
Provider Business Mailing Address Fax Number:
801-743-4705

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1140 E 3900 S
Provider Second Line Business Practice Location Address:
SUITE 390
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:
84124-1228
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-743-4700
Provider Business Practice Location Address Fax Number:
801-743-4705
Provider Enumeration Date:
06/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KANE
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
VP
Authorized Official Telephone Number:
801-568-5999

Provider Taxonomy Codes

  • Taxonomy code: 207VM0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 60271256 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200134000A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1457393084 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 807101900 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 121073400 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1457393084 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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