Basic Information
| Provider Information | |||||||||
| NPI: | 1457393084 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MATERNAL FETAL SERVICES OF UTAH LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1140 E 3900 S | ||||||||
| Address2: | SUITE 390 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841241228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017434700 | ||||||||
| FaxNumber: | 8017434705 | ||||||||
| Practice Location | |||||||||
| Address1: | 1140 E 3900 S | ||||||||
| Address2: | SUITE 390 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841241228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017434700 | ||||||||
| FaxNumber: | 8017434705 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2006 | ||||||||
| LastUpdateDate: | 05/20/2010 | ||||||||
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| AuthorizedOfficialLastName: | KANE | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 8015685999 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VM0101X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 60271256 | 05 | CO | MEDICAID | 200134000A | 05 | OK | MEDICAID | 1457393084 | 05 | NV | MEDICAID | 807101900 | 05 | ID | MEDICAID | 121073400 | 05 | WY | MEDICAID | 1457393084 | 05 | VA | MEDICAID |