1922115963 NPI number — UNIVERSITY OF UTAH PAIN MANAGEMENT PHYSICIANS GROUP

Table of content: (NPI 1922115963)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922115963 NPI number — UNIVERSITY OF UTAH PAIN MANAGEMENT PHYSICIANS GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UNIVERSITY OF UTAH PAIN MANAGEMENT PHYSICIANS GROUP
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:
1922115963
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/12/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 413034
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:
84141-3034
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-213-3900
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
546 S CHIPETA WAY
Provider Second Line Business Practice Location Address:
220
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:
84108-1221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-581-7172
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CAHALAN
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
K
Authorized Official Title or Position:
DEPARTMENT CHAIR
Authorized Official Telephone Number:
801-581-6393

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207LP2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100502709 . This is a "NEVADA MEDICAID" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: 172970100 . This is a "DEPT OF LABOR" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 122767000 . This is a "WYOMING MEDICAID" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 806360300 . This is a "IDAHO MEDICAID" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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