Basic Information
| Provider Information | |||||||||
| NPI: | 1215192026 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MYELOMA CARE DEPARTMENT OF UNIVERSITY OF UTAH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UUMC - MYELOMA CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 413033 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841410001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015812121 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1950 CIRCLE OF HOPE DR | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841125500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015812121 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2008 | ||||||||
| LastUpdateDate: | 04/14/2009 | ||||||||
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| AuthorizedOfficialLastName: | MADONNA | ||||||||
| AuthorizedOfficialFirstName: | JANELL | ||||||||
| AuthorizedOfficialMiddleName: | I | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF CONTRACTING AND PE | ||||||||
| AuthorizedOfficialTelephone: | 8015876464 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 808154300 - MID | 05 | ID | MEDICAID | 808115200 | 05 | ID | MEDICAID | DN9494 | 01 | UT | RR MEDICARE | OTHER |