1780681775 NPI number — SCOTT ERICKSON

Table of content: SCOTT ERICKSON (NPI 1780681775)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780681775 NPI number — SCOTT ERICKSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ERICKSON
Provider First Name:
SCOTT
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780681775
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/21/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
SCOTT ERICKSON
Provider Second Line Business Mailing Address:
440 MEDICAL DR
Provider Business Mailing Address City Name:
BOUNTIFUL
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84010-4950
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
807-294-8288
Provider Business Mailing Address Fax Number:
801-294-8488

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
440 MEDICAL DR
Provider Second Line Business Practice Location Address:
SUITE 4
Provider Business Practice Location Address City Name:
BOUNTIFUL
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84010-4950
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
807-294-8288
Provider Business Practice Location Address Fax Number:
801-294-8488
Provider Enumeration Date:
07/05/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  5836179-1205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: D6126 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com