1770597726 NPI number — DR. SUSAN MARIE WIET M.D.

Table of content: (NPI 1437772795)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770597726 NPI number — DR. SUSAN MARIE WIET M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WIET
Provider First Name:
SUSAN
Provider Middle Name:
MARIE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1770597726
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/04/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
850 E 300 S STE 1
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:
84102-2301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
385-429-9808
Provider Business Mailing Address Fax Number:
844-838-8100

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
160 S 1000 E STE 220
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:
84102-1552
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-743-9438
Provider Business Practice Location Address Fax Number:
844-838-8100
Provider Enumeration Date:
07/27/2006

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: 2084P0800X , with the licence number:  371106 , 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)

  • Identifier: 37110612001001 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 70927 . This is a "PUBLIC EMPLOYEES HEALTH P" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 870663870SW2 . This is a "EMIA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".