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Organization
PEDIATRIC ADOLESCENT MEDICINE DEPARTMENT OF UNIVERISTY OF UTAH
Active
Organization
PEDIATRIC ADOLESCENT MEDICINE DEPARTMENT OF UNIVERISTY OF UTAH
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. EDWARD B CLARK MD (CHAIR)
(801) 587-7400
Entity
Organization
Contact information
Practice address
50 N MEDICAL DR, SALT LAKE CITY, UT 84132-0001
(801) 581-3501
(801) 581-4920
Mailing address
295 CHIPETA WAY, PEDS ADMIN, SALT LAKE CITY, UT 84108-1220
(801) 587-7400
(801) 587-7417
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
—
—
2080A0000X
Pediatric Adolescent Medicine Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100507432
—
NV
05
—
121820400
—
WY
05
—
807297100
—
ID
Enumeration date
05/20/2006
Last updated
09/06/2011
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