Provider Demographics
NPI:1548308067
Name:SKIN PATHOLOGY CONSULTANTS OF UTAH
Entity type:Organization
Organization Name:SKIN PATHOLOGY CONSULTANTS OF UTAH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR LED
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:VITALE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-261-3007
Mailing Address - Street 1:168 E 5900 S
Mailing Address - Street 2:STE C104
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-7287
Mailing Address - Country:US
Mailing Address - Phone:801-261-3007
Mailing Address - Fax:801-263-6703
Practice Address - Street 1:168 E 5900 S
Practice Address - Street 2:STE C104
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-7287
Practice Address - Country:US
Practice Address - Phone:801-261-3007
Practice Address - Fax:801-263-6703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5228084-1205207ZD0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1558466177OtherINDIVIDUAL NPI NUMBER
UT140649593001Medicaid
UT140649593001Medicaid