Basic Information
| Provider Information | |||||||||
| NPI: | 1689840209 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PEDIATRIC ALLERGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 295 CHIPETA WAY | ||||||||
| Address2: | U OF U SOM DEPT OF PEDIATRICS | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841081220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015877400 | ||||||||
| FaxNumber: | 8015877417 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 MARIO CAPECCHI DR | ||||||||
| Address2: | PEDIATRIC ALLERGY | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841131103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8016622100 | ||||||||
| FaxNumber: | 8016622120 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2008 | ||||||||
| LastUpdateDate: | 08/10/2010 | ||||||||
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| AuthorizedOfficialLastName: | CLARK | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | CHAIRPERSON | ||||||||
| AuthorizedOfficialTelephone: | 8015877400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0201X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Allergy/Immunology |
No ID Information.