Basic Information
| Provider Information | |||||||||
| NPI: | 1982642252 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY OF UTAH HOSPITALS AND CLINICS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 510708 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841510708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015876303 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1525 W 2100 S | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841191401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012139900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 09/07/2011 | ||||||||
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| AuthorizedOfficialLastName: | TERRY | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8015876307 | ||||||||
| IsSoleProprietor: | |||||||||
| 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 | 152W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 208100000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 213E00000X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 163W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | 367A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | CN8305 | 01 | UT | RAILROAD MEDICARE | OTHER | 100503428 | 05 | NV | MEDICAID | 100503428 | 05 | WY | MEDICAID | 807076400 | 05 | ID | MEDICAID | CI9541 | 01 | UT | RAILROAD MEDICARE | OTHER | 807159300 | 05 | ID | MEDICAID | CN7381 | 01 | UT | RAILROAD MEDICARE | OTHER |