1457737579 NPI number — UTAH PODIATRY GROUP PC

Table of content: (NPI 1457737579)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457737579 NPI number — UTAH PODIATRY GROUP PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UTAH PODIATRY GROUP PC
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:
6
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:
1457737579
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 30015 DEPT 380
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:
84130-0015
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-373-2499
Provider Business Mailing Address Fax Number:
801-373-5200

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1973 NORTH STATE STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PROVO
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84604-1012
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-373-2499
Provider Business Practice Location Address Fax Number:
801-373-5200
Provider Enumeration Date:
07/31/2015

Additional Information

Authorized Official

Authorized Official Last Name:
TAYLOR
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
801-505-0821

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6152070001 . This is a "DME PTAN" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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