Provider Demographics
NPI:1154883668
Name:PHYSICIAN GROUP OF UTAH INC
Entity type:Organization
Organization Name:PHYSICIAN GROUP OF UTAH INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:K
Authorized Official - Last Name:WILKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-984-3293
Mailing Address - Street 1:PO BOX 281415
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-1415
Mailing Address - Country:US
Mailing Address - Phone:800-673-1270
Mailing Address - Fax:314-432-9683
Practice Address - Street 1:5979 S 300 E
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-7364
Practice Address - Country:US
Practice Address - Phone:801-263-2370
Practice Address - Fax:801-265-1200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-03
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty