Provider Demographics
NPI:1215287503
Name:EDWARD G. SOUTHWICK, M.D., P.C.
Entity type:Organization
Organization Name:EDWARD G. SOUTHWICK, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:GLEN
Authorized Official - Last Name:SOUTHWICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-966-1403
Mailing Address - Street 1:3465 S 4155 W
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84120-2076
Mailing Address - Country:US
Mailing Address - Phone:801-966-1403
Mailing Address - Fax:801-964-6478
Practice Address - Street 1:3465 S 4155 W
Practice Address - Street 2:SUITE 1
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-2076
Practice Address - Country:US
Practice Address - Phone:801-966-1403
Practice Address - Fax:801-964-6478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT071157009OtherRAILROAD MEDICARE
UT071157009OtherRAILROAD MEDICARE
UTU000000571Medicare PIN