Basic Information
| Provider Information | |||||||||
| NPI: | 1467414581 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAILLAC | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3439 CANYON COVE DR | ||||||||
| Address2: | |||||||||
| City: | HOLLADAY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841216335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012727606 | ||||||||
| FaxNumber: | 8012725399 | ||||||||
| Practice Location | |||||||||
| Address1: | UNIVERSITY OF UTAH DIVISION OF EMERGENCY MEDICINE | ||||||||
| Address2: | 30 NORTH 1900 EAST ROOM 1C026 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841320001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015812417 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2006 | ||||||||
| LastUpdateDate: | 12/16/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | 279025-1205 | UT | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | D1205 | 05 | UT | MEDICAID |