Pediatric Adolescent Medicine Department of Univeristy of Utah

Primary specialty

Pediatric Adolescent Medicine PhysicianTaxonomy code 2080A0000X

Legal business name

PEDIATRIC ADOLESCENT MEDICINE DEPARTMENT OF UNIVERISTY OF UTAH

Practice address

50 N Medical Dr
Salt Lake City, UT 84132-0001

Phone

(801) 581-3501

Fax

(801) 581-4920

NPI assigned

May 20, 2006

Last updated

Sep 6, 2011By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Dr. Edward B Clark, MD

Title

Chair

Phone

(801) 587-7400

Specialties & licenses 2

Addresses

Other identifiers 3

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

{
    "created_epoch": "1148083200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1315267200000",
    "number": "1639123896",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "295 CHIPETA WAY",
            "address_2": "PEDS ADMIN",
            "city": "SALT LAKE CITY",
            "state": "UT",
            "postal_code": "841081220",
            "telephone_number": "801-587-7400",
            "fax_number": "801-587-7417"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "50 N MEDICAL DR",
            "city": "SALT LAKE CITY",
            "state": "UT",
            "postal_code": "841320001",
            "telephone_number": "801-581-3501",
            "fax_number": "801-581-4920"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PEDIATRIC ADOLESCENT MEDICINE DEPARTMENT OF UNIVERISTY OF UTAH",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-20",
        "last_updated": "2011-09-06",
        "status": "A",
        "authorized_official_last_name": "CLARK",
        "authorized_official_first_name": "EDWARD",
        "authorized_official_middle_name": "B",
        "authorized_official_title_or_position": "CHAIR",
        "authorized_official_telephone_number": "801-587-7400",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "2080A0000X",
            "taxonomy_group": "",
            "desc": "Pediatrics, Adolescent Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100507432",
            "state": "NV"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "121820400",
            "state": "WY"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "807297100",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Melissa Lee Pedersen, RN
• Peder J Pedersen, M.D.
• Amber Pederson
• Elise Pederson
• T M Pederson, LCSW
• Pediatric Allergy
• Pediatric Anesthesiologists Inc
• Pediatric Behavioral Health
• Pediatric Bone Marrow Transplant Department of University of Utah
• Pediatric Cardiology Department of University of Utah

• Pediatric Adolescent Medicine Physician in Salt Lake City, UT
• Providers in Salt Lake City, UT by specialty
• Pediatric Adolescent Medicine Physician in Utah

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 6, 2011; 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.