Basic Information
| Provider Information | |||||||||
| NPI: | 1760490122 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTH SUMMIT PEDIATRICS. LLC | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 267 E TRAVERSEPOINT DRIVE | ||||||||
| Address2: | |||||||||
| City: | DRAPER | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015679780 | ||||||||
| FaxNumber: | 8015679826 | ||||||||
| Practice Location | |||||||||
| Address1: | 267 E TRAVERSEPOINT DRIVE | ||||||||
| Address2: | |||||||||
| City: | DRAPER | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015679780 | ||||||||
| FaxNumber: | 8015679826 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 11/13/2007 | ||||||||
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| AuthorizedOfficialLastName: | LEI | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8015679780 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 173000000X | 363788-1205 | UT | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Legal Medicine |
No ID Information.