NPIMap

Organization Active NPI

Caresource

  • Hospice and Palliative Medicine (Family Medicine) Physician
  • Salt Lake City, UT
National Provider Identifier
1124242128
Registry record updated Sep 11, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Hospice and Palliative Medicine (Family Medicine) PhysicianTaxonomy code 207QH0002X
License
5221090-1205 Issued in UT
Legal business name
CARESOURCE
Practice address
1624 E 4500 S
Salt Lake City, UT 84117-4212
Phone
(801) 266-7200
Fax
(801) 266-7004
NPI assigned
Apr 12, 2007
Last updated
Sep 11, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 11, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Shawntel Tanner, MA
Title
Administrator
Phone
(801) 266-7200

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 5221090-1205 UT
Hospice and Palliative Medicine (Family Medicine) Physician 207QH0002X 5221090-1205 UT Primary

Addresses

Primary practice location

1624 E 4500 S
Salt Lake City, UT 84117-4212

Mailing address

1624 E 4500 S
Salt Lake City, UT 84117-4212
Phone (801) 266-7200

Other names 1

  • CareSource Senior Supportive Care Center Other name

National Provider Directory

National Provider Directory
Tax ID family
Caresource3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1176336000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1757548800000",
    "number": "1124242128",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1624 E 4500 S",
            "city": "SALT LAKE CITY",
            "state": "UT",
            "postal_code": "841174212",
            "telephone_number": "801-266-7200",
            "fax_number": "801-266-7004"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1624 E 4500 S",
            "city": "SALT LAKE CITY",
            "state": "UT",
            "postal_code": "841174212",
            "telephone_number": "801-266-7200",
            "fax_number": "801-266-7004"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CARESOURCE",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-04-12",
        "last_updated": "2025-09-11",
        "status": "A",
        "authorized_official_last_name": "TANNER",
        "authorized_official_first_name": "SHAWNTEL",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "801-266-7200",
        "authorized_official_name_prefix": "Mrs.",
        "authorized_official_credential": "MA"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "UT",
            "license": "5221090-1205",
            "primary": false
        },
        {
            "code": "207QH0002X",
            "taxonomy_group": "",
            "desc": "Family Medicine, Hospice and Palliative Medicine",
            "state": "UT",
            "license": "5221090-1205",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "CareSource Senior Supportive Care Center",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Salt Lake City, UT

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 11, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.