Basic Information
| Provider Information | |||||||||
| NPI: | 1023542388 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY OF UTAH PEDIATRIC SERVICES | ||||||||
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| OtherOrganizationName: | MISSOULA BONE & JOINT SURGICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 841450 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900841450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012133900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2360 MULLAN RD | ||||||||
| Address2: | SUTIE C | ||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598081811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4065429695 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2017 | ||||||||
| LastUpdateDate: | 01/22/2021 | ||||||||
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| AuthorizedOfficialLastName: | FINLAYSON | ||||||||
| AuthorizedOfficialFirstName: | SAMUEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF CLINICAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8015876336 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UNIVERSITY OF UTAH PEDIATRIC SERVICES | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 01/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207XP3100X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Pediatric Orthopaedic Surgery |
No ID Information.