Provider Demographics
NPI:1730568445
Name:AMERICAN FORK PEDIATRICS, INC.
Entity type:Organization
Organization Name:AMERICAN FORK PEDIATRICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:WHITING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-492-4333
Mailing Address - Street 1:48 N 1100 E
Mailing Address - Street 2:SUITE C
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-2910
Mailing Address - Country:US
Mailing Address - Phone:801-492-4333
Mailing Address - Fax:801-492-4371
Practice Address - Street 1:48 N 1100 E
Practice Address - Street 2:SUITE C
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-2910
Practice Address - Country:US
Practice Address - Phone:801-492-4333
Practice Address - Fax:801-492-4371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-27
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT168875-1205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT534542093027Medicaid