Basic Information
| Provider Information | |||||||||
| NPI: | 1265640882 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GARRETT | ||||||||
| FirstName: | CAROLINE | ||||||||
| MiddleName: | SUE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 27128 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841270128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014647788 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2000 S 900 E | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841053208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014647788 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2007 | ||||||||
| LastUpdateDate: | 05/10/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | TP722 | KY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | TP722 | KY | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 9433313-1205 | UT | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 7100083150 | 05 | KY | MEDICAID | 0703006 | 01 | PTAN | OTHER |