Basic Information
| Provider Information | |||||||||
| NPI: | 1639124498 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY RADIOLOGY ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 413025 | ||||||||
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| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841410001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012133800 | ||||||||
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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: | 8015812121 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 04/14/2009 | ||||||||
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| AuthorizedOfficialLastName: | MADONNA | ||||||||
| AuthorizedOfficialFirstName: | JANELL | ||||||||
| AuthorizedOfficialMiddleName: | I | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF CONTRACTING AND PE | ||||||||
| AuthorizedOfficialTelephone: | 8015876464 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 | 2085N0700X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085N0904X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085R0203X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Therapeutic Radiology | 2085R0204X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085U0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 002088594 | 05 | NV | MEDICAID | 000125500 | 05 | ID | MEDICAID | 7001100 | 05 | WA | MEDICAID | 74037502 | 05 | TX | MEDICAID | 000G5119 | 05 | NM | MEDICAID | 120932900 | 05 | WY | MEDICAID | 027071999 | 01 | DEPT OF LABOR | OTHER |