Basic Information
| Provider Information | |||||||||
| NPI: | 1417983776 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY OF UTAH OB DIAGNOSTIC CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 58859 | ||||||||
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| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841580859 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015855172 | ||||||||
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| Practice Location | |||||||||
| Address1: | 50 N MEDICAL DR | ||||||||
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| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841320001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015812719 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2006 | ||||||||
| LastUpdateDate: | 06/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | PETERSON | ||||||||
| AuthorizedOfficialFirstName: | C. MATTHEW | ||||||||
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| AuthorizedOfficialTitleorPosition: | DEPARTMENT CHAIR | ||||||||
| AuthorizedOfficialTelephone: | 8015812719 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085R0202X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085U0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound |
ID Information
| ID | Type | State | Issuer | Description | 003054800 | 01 | ID | IDAHO MEDICAID | OTHER | 870410144009 | 05 | UT | MEDICAID | 100503089 | 01 | NV | NEVADA MEDICAID | OTHER | 117769900 | 01 | WY | WYOMING MEDICAID | OTHER |