# PEDIATRIC PM AND R

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1760776223
- **Authorized official:** DR. ELIE P ELOVIC MD (CHAIR)
- **Authorized official phone:** (801) 662-4949

## Contact information

- **Practice address:** 100 MARIO CAPECCHI DR, ROOM 4400, SALT LAKE CITY, UT 84113-1103
- **Practice address phone:** (801) 662-4949
- **Practice address fax:** (801) 662-4931
- **Mailing address:** PO BOX 413032, SALT LAKE CITY, UT 84141-3032
- **Mailing address phone:** (801) 213-3900
- **Mailing address fax:** (801) 585-3655

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 208100000X | Physical Medicine & Rehabilitation Physician | 72775361205 | UT | — |
| 2081P0010X | Pediatric Rehabilitation Medicine Physician | 72775361205 | UT | Yes |

## Other

- **Enumeration date:** 06/01/2011
- **Last updated:** 06/01/2011