NPIMap

Organization Active NPI

University of Utah Pediatric Services

  • Neurology with Special Qualifications in Child Neurology Physician
  • Idaho Falls, ID
National Provider Identifier
1669918769
Registry record updated May 21, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Neurology with Special Qualifications in Child Neurology PhysicianTaxonomy code 2084N0402X
Legal business name
UNIVERSITY OF UTAH PEDIATRIC SERVICES
Practice address
1645 Pancheri Dr
Idaho Falls, ID 83402-3169
Phone
(208) 227-1460
NPI assigned
Jan 12, 2017
Organization subpart
Yes
Parent organization
UNIVERSITY OF UTAH PEDIATRIC SERVICESAs reported in NPPES

NPPES NPI Registry

Updated by the provider on May 21, 2020

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

Authorized official

Name
Edward Clark, MD
Title
Department Chair
Phone
(801) 587-6336

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatrics PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208000000X
Neurology with Special Qualifications in Child Neurology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2084N0402X Primary

Addresses

Primary practice location

1645 Pancheri Dr
Idaho Falls, ID 83402-3169

Mailing address

PO Box 841450
Los Angeles, CA 90084-1450
Phone (801) 213-3900

Other names 1

  • Pediatric Neurology - Idaho Falls Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20160728000531 ID Part B Supplier - Clinic/Group Practice 0547552473 Receives reassigned benefits from 12 practitioners
11 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Idaho Falls, ID; Rexburg, ID; Pocatello, ID; Blackfoot, ID

Other NPIs on the same Medicare enrollment 11

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
University of Utah Pediatric Services35 organizations share this tax ID, including this one
Part of
University of Utah Pediatric Services

Other organizations with this tax ID 34

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

View all 34

NPI Registry JSON

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

{
    "created_epoch": "1484179200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1590019200000",
    "number": "1669918769",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 841450",
            "city": "LOS ANGELES",
            "state": "CA",
            "postal_code": "900841450",
            "telephone_number": "801-213-3900"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1645 PANCHERI DR",
            "city": "IDAHO FALLS",
            "state": "ID",
            "postal_code": "834023169",
            "telephone_number": "208-227-1460"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "UNIVERSITY OF UTAH PEDIATRIC SERVICES",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "UNIVERSITY OF UTAH PEDIATRIC SERVICES",
        "enumeration_date": "2017-01-12",
        "last_updated": "2020-05-21",
        "certification_date": "2020-05-21",
        "status": "A",
        "authorized_official_last_name": "CLARK",
        "authorized_official_first_name": "EDWARD",
        "authorized_official_title_or_position": "DEPARTMENT CHAIR",
        "authorized_official_telephone_number": "801-587-6336",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pediatrics",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2084N0402X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychiatry & Neurology, Neurology with Special Qualifications in Child Neurology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Pediatric Neurology - Idaho Falls",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Pediatric Neurology - Idaho Falls",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Idaho Falls, ID

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 21, 2020; 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.