Provider Demographics
NPI:1053594861
Name:PETER V SUNDWALL MD PCA
Entity type:Organization
Organization Name:PETER V SUNDWALL MD PCA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:V
Authorized Official - Last Name:SUNDWALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD PCA
Authorized Official - Phone:801-262-2443
Mailing Address - Street 1:4815 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-4814
Mailing Address - Country:US
Mailing Address - Phone:801-262-2443
Mailing Address - Fax:801-262-8869
Practice Address - Street 1:4815 CENTER ST
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-4814
Practice Address - Country:US
Practice Address - Phone:801-262-2443
Practice Address - Fax:801-262-8869
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-14
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1498871205207Q00000X
UT1498878905207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528447834000Medicaid
UT0773070001Medicare NSC
UT528447834000Medicaid