Basic Information
| Provider Information | |||||||||
| NPI: | 1013245000 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDELIN | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | ALLEN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 27128 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841270128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013875300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4403 HARRISON BLVD | ||||||||
| Address2: | STE A-700 | ||||||||
| City: | OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844033271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013875300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2009 | ||||||||
| LastUpdateDate: | 11/16/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 7730028-1205 | UT | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 2012003966 | MO | N | Allopathic & Osteopathic Physicians | Family Medicine | 208M00000X | 2012003966 | MO | N | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 1013245000 | 05 | UT | MEDICAID |