Basic Information
| Provider Information | |||||||||
| NPI: | 1780088351 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNIVERSITY OF UTAH COMMUNITY PHYSICIANS GROUP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UUHC-SOUTH JORDAN HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 510708 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841510708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012133900 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5126 W DAYBREAK PKWY | ||||||||
| Address2: | STE 600 | ||||||||
| City: | SOUTH JORDAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840955994 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015876336 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2014 | ||||||||
| LastUpdateDate: | 10/10/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MULVIHILL | ||||||||
| AuthorizedOfficialFirstName: | SEAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF MEDICAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8015876336 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UNIVERSITY OF UTAH COMMUNITY PHYSICIANS GROUP | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.