Organization
PEDIATRIC GASTROENTEROLOGY DEPARTMENT OF UNIVERSITY 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
100 N MEDICAL DR, SALT LAKE CITY, UT 84113-1103
(801) 588-3370
(801) 588-2375
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
—
—
2080P0206X
Pediatric Gastroenterology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100507106
—
NV
05
—
121245100
—
WY
05
—
807149700
—
ID
Enumeration date
05/19/2006
Last updated
09/06/2011
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