Basic Information
| Provider Information | |||||||||
| NPI: | 1922052604 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRIC CRITICAL CARE DEPARTMENT OF UNIVERSITY OF UTAH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 295 CHIPETA WAY | ||||||||
| Address2: | PEDS ADMIN | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841081220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015877400 | ||||||||
| FaxNumber: | 8015877417 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 MARIO CAPECCHI DR | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841131103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8016621000 | ||||||||
| FaxNumber: | 8012133320 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 06/25/2009 | ||||||||
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| AuthorizedOfficialLastName: | CLARK | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | CHAIR | ||||||||
| AuthorizedOfficialTelephone: | 8015877400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0203X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100507101 | 05 | NV | MEDICAID | 121357100 | 05 | WY | MEDICAID | 807147600 | 05 | ID | MEDICAID |