Basic Information
| Provider Information | |||||||||
| NPI: | 1124235312 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENDRY | ||||||||
| FirstName: | TRAVIS | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1551 RENAISSANCE TOWNE DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | BOUNTIFUL | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840107676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012957200 | ||||||||
| FaxNumber: | 8012954930 | ||||||||
| Practice Location | |||||||||
| Address1: | 1551 RENAISSANCE TOWNE DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | BOUNTIFUL | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840107676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012957200 | ||||||||
| FaxNumber: | 8012954930 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2007 | ||||||||
| LastUpdateDate: | 11/16/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 0101245156 | VA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 353125-1205 | UT | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1124235312 | 05 | UT | MEDICAID | P00869950 | 01 | UT | MEDICARE RAILROAD | OTHER |