Basic Information
| Provider Information | |||||||||
| NPI: | 1013008077 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1954 FORT UNION BLVD | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841216800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019939530 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1200 E 3900 S | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841241300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019939530 | ||||||||
| FaxNumber: | 8017335618 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 4985237-1205 | UT | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 236437 | 01 | UT | ALTIUS | OTHER | 000009351150 | 01 | UT | PHCS | OTHER | TPRA1129 | 01 | UT | MOLINA | OTHER | 83147 | 01 | UT | PEHP | OTHER | 878277 | 01 | UT | DESERET MUTUAL | OTHER | 38892 | 01 | UT | HEALTHY U | OTHER | 7710087 | 01 | UT | CIGNA | OTHER | 107037417102 | 01 | UT | IHC | OTHER |