Basic Information
| Provider Information | |||||||||
| NPI: | 1811056260 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UROLOGY CLINIC OF UTAH VALLEY | ||||||||
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| OtherOrganizationName: | THE UROLOGY CLINIC OF UTAH VALLEY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1055 N 300 W | ||||||||
| Address2: | STE 316 | ||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013577530 | ||||||||
| FaxNumber: | 8013577566 | ||||||||
| Practice Location | |||||||||
| Address1: | 1055 N 300 W | ||||||||
| Address2: | STE 316 | ||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013577530 | ||||||||
| FaxNumber: | 8013577566 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2006 | ||||||||
| LastUpdateDate: | 09/21/2007 | ||||||||
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| AuthorizedOfficialLastName: | LANDAU | ||||||||
| AuthorizedOfficialFirstName: | STEWART | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8013577530 | ||||||||
| 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 | 2088P0231X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | Pediatric Urology | 208800000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
No ID Information.