Basic Information
| Provider Information | |||||||||
| NPI: | 1316277635 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY OF UTAH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1952 MAPLE HOLLOW WAY | ||||||||
| Address2: | |||||||||
| City: | BOUNTIFUL | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840101041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012051003 | ||||||||
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| Practice Location | |||||||||
| Address1: | 50 N MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841320001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015816393 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2010 | ||||||||
| LastUpdateDate: | 01/08/2010 | ||||||||
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| AuthorizedOfficialLastName: | LOOSE | ||||||||
| AuthorizedOfficialFirstName: | EVELYN | ||||||||
| AuthorizedOfficialMiddleName: | CHARLOTTE | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT PROFESSOR | ||||||||
| AuthorizedOfficialTelephone: | 8012051003 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 3674091205 | UT | N | Hospitals | General Acute Care Hospital | Critical Access | 282N00000X | 3764091205 | UT | Y | Hospitals | General Acute Care Hospital |
No ID Information.