Basic Information
| Provider Information | |||||||||
| NPI: | 1972744357 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IHC HEALTH SERVICES INC | ||||||||
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| OtherOrganizationName: | PARK CITY MEDICAL CENTER PHYSICIANS GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4646 LAKE PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841208212 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 900 ROUND VALLEY DR | ||||||||
| Address2: | |||||||||
| City: | PARK CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840607532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356587000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2009 | ||||||||
| LastUpdateDate: | 02/15/2019 | ||||||||
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| AuthorizedOfficialLastName: | WESTON | ||||||||
| AuthorizedOfficialFirstName: | LORI | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4356586719 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.