Provider Demographics
NPI:1386699676
Name:WESTERN UROLOGICAL CLINIC PC
Entity type:Organization
Organization Name:WESTERN UROLOGICAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LANE
Authorized Official - Middle Name:C
Authorized Official - Last Name:CHILDS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-993-1800
Mailing Address - Street 1:4252 HIGHLAND DR
Mailing Address - Street 2:#200
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84124-2670
Mailing Address - Country:US
Mailing Address - Phone:801-993-1800
Mailing Address - Fax:801-993-1699
Practice Address - Street 1:4252 HIGHLAND DR
Practice Address - Street 2:#200
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84124-2670
Practice Address - Country:US
Practice Address - Phone:801-993-1800
Practice Address - Fax:801-993-1699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD90095Medicare UPIN
UTD20171Medicare UPIN
UTC68665Medicare UPIN
UTH18395Medicare UPIN
UTQ25514Medicare UPIN