Provider Demographics
NPI:1053360917
Name:WASATCH MEDICAL CENTER
Entity type:Organization
Organization Name:WASATCH MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:NOEL
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-225-5264
Mailing Address - Street 1:575 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84058-6303
Mailing Address - Country:US
Mailing Address - Phone:801-225-5264
Mailing Address - Fax:801-229-2420
Practice Address - Street 1:575 S STATE ST
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058-6303
Practice Address - Country:US
Practice Address - Phone:801-225-5264
Practice Address - Fax:801-229-2420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2007-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty