OrganizationPark City Internal Medicine - Pediatrics, LcClinic/CenterAmbulatory Health Care FacilitiesPractice Address1612 Ute Blvd, Ste 205, Park City, UT 84098-7500(435) 655-3309PECOS EnrollmentBased on the most recent information from CMS, provider Park City Internal Medicine - Pediatrics, Lc does not have current enrollment records in PECOS.Part BMedicare Part BNot EnrolledHHAHome Health AgencyNot EnrolledDMEDurable Medical EquipmentNot EnrolledPMDPower Mobility DeviceNot EnrolledCMS last updated its PECOS records 11 days ago.Profile DetailsProvider ID1750569562Provider TypeOrganizationFull NamePark City Internal Medicine - Pediatrics, LcSubpartNoEnumeration Date2/4/2008Last Updated5/18/2011Contact InformationPractice LocationPractice Address1612 Ute Blvd, Ste 205, Park City, UT 84098-7500Phone(435) 655-3309Fax(435) 655-3392Mailing LocationMailing Address1612 Ute Blvd, Ste 205, Park City, UT 84098-7500Phone(435) 655-3309Fax(435) 655-3392Authorized OfficialNamePeacock, Penny (Owner)Phone(435) 655-3309Provider TaxonomiesCodeDescriptionLicenseCode261QH0100XPrimaryDescriptionClinic/CenterAmbulatory Health Care FacilitiesLicense5151398-1205Utah