NPIMap

Organization Active NPI

Olympus Clinic

  • Family Medicine Physician
  • Salt Lake City, UT
National Provider Identifier
1508810508
Registry record updated Mar 4, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
5533 Issued in UT
Legal business name
OLYMPUS CLINIC
Practice address
4624 Holladay Blvd
Salt Lake City, UT 84117-5206
Phone
(801) 277-2682
Fax
(801) 277-2980
NPI assigned
May 22, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 4, 2008

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

Authorized official

Name
Troy A Fuller
Title
Office Manager
Phone
(801) 277-2682

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X 5533 UT Primary

Addresses

Primary practice location

4624 Holladay Blvd
Salt Lake City, UT 84117-5206

Mailing address

4624 Holladay Blvd
Salt Lake City, UT 84117-5206
Phone (801) 277-2682

Other identifiers 1

IdentifierTypeStateIssuer
CP7822OtherUTMEDICARE RAILROAD

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in UT

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040206000213 UT Part B Supplier - Clinic/Group Practice 8921991506 Receives reassigned benefits from 14 practitioners
Practice locations: Salt Lake City, UT

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 14

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 14

NPI Registry JSON

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

{
    "created_epoch": "1148256000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1204588800000",
    "number": "1508810508",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4624 HOLLADAY BLVD",
            "city": "SALT LAKE CITY",
            "state": "UT",
            "postal_code": "841175206",
            "telephone_number": "801-277-2682",
            "fax_number": "801-277-2980"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4624 HOLLADAY BLVD",
            "city": "SALT LAKE CITY",
            "state": "UT",
            "postal_code": "841175206",
            "telephone_number": "801-277-2682",
            "fax_number": "801-277-2980"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "OLYMPUS CLINIC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-22",
        "last_updated": "2008-03-04",
        "status": "A",
        "authorized_official_last_name": "FULLER",
        "authorized_official_first_name": "TROY",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "OFFICE MANAGER",
        "authorized_official_telephone_number": "801-277-2682"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": "UT",
            "license": "5533",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE RAILROAD",
            "identifier": "CP7822",
            "state": "UT"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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 Mar 4, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.