NPIMap

Organization Active NPI

Department of Pediatrics University of Utah

  • Pediatrics Physician
  • Salt Lake City, UT
National Provider Identifier
1679528715
Registry record updated Sep 6, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatrics PhysicianTaxonomy code 208000000X
Legal business name
DEPARTMENT OF PEDIATRICS UNIVERSITY OF UTAH
Practice address
100 N Medical Dr
Salt Lake City, UT 84113-1103
Phone
(801) 588-2000
Fax
(801) 587-7417
NPI assigned
May 24, 2006
Last updated
Sep 6, 2011By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 6, 2011

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

Authorized official

Name
Edward B Clark, MD
Title
Chair
Phone
(801) 587-7400

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatrics Physician 208000000X NU Primary

Addresses

Primary practice location

100 N Medical Dr
Salt Lake City, UT 84113-1103

Mailing address

295 Chipeta Way
Peds Admin
Salt Lake City, UT 84108-1220
Phone (801) 587-7400

Other identifiers 10

IdentifierTypeStateIssuer
911948500MedicaidFL
G0749MedicaidNM
003057700MedicaidID
806902200MedicaidID
200426530AMedicaidIN
176668501MedicaidTX
100500257MedicaidNV
200020440AMedicaidOK
7038870MedicaidWA
94001963MedicaidCO

National Provider Directory

National Provider Directory

Locations

100 N Mario Capecchi Dr
#U
Salt Lake City, UT 84113

Practitioners & affiliated clinicians

Practitioners 187

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 187

NPI Registry JSON

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

{
    "created_epoch": "1148428800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1315267200000",
    "number": "1679528715",
    "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": "100 N MEDICAL DR",
            "city": "SALT LAKE CITY",
            "state": "UT",
            "postal_code": "841131103",
            "telephone_number": "801-588-2000",
            "fax_number": "801-587-7417"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DEPARTMENT OF PEDIATRICS UNIVERSITY OF UTAH",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-24",
        "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_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "911948500",
            "state": "FL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "G0749",
            "state": "NM"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "003057700",
            "state": "ID"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "806902200",
            "state": "ID"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200426530A",
            "state": "IN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "176668501",
            "state": "TX"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100500257",
            "state": "NV"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200020440A",
            "state": "OK"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7038870",
            "state": "WA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "94001963",
            "state": "CO"
        }
    ],
    "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 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.