Provider Demographics
NPI:1699796706
Name:UNIVERSITY PRIMARY CARE SPORTS MED
Entity type:Organization
Organization Name:UNIVERSITY PRIMARY CARE SPORTS MED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPARTMENT CHAIR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:K
Authorized Official - Last Name:MAGILL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-585-5382
Mailing Address - Street 1:PO BOX 510004
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84151-0004
Mailing Address - Country:US
Mailing Address - Phone:801-587-6303
Mailing Address - Fax:
Practice Address - Street 1:555 FOOTHILL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84112-1106
Practice Address - Country:US
Practice Address - Phone:801-585-5382
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807551900OtherIDAHO MEDICAID
UTDG1456OtherRAILROAD MEDICARE
NV100510167OtherNEVADA MEDICAID
WY123613000OtherWYOMING MEDICAID
UTDG1456OtherRAILROAD MEDICARE
NV100510167OtherNEVADA MEDICAID