Provider Demographics
NPI:1083642151
Name:SMP FAMILY MEDICINE, PC
Entity type:Organization
Organization Name:SMP FAMILY MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLA
Authorized Official - Middle Name:IRENE
Authorized Official - Last Name:RILEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-747-0922
Mailing Address - Street 1:PO BOX 932
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84091-0932
Mailing Address - Country:US
Mailing Address - Phone:801-553-9568
Mailing Address - Fax:801-553-9562
Practice Address - Street 1:1220 E 3900 S
Practice Address - Street 2:SUITE 4A
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1377
Practice Address - Country:US
Practice Address - Phone:801-747-0922
Practice Address - Fax:801-747-0924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT56658201205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT099643665001Medicaid
UT000058035Medicare PIN
UTI 36423Medicare UPIN