Basic Information
| Provider Information | |||||||||
| NPI: | 1669628434 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENDRICKSON | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | CURTIS | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3750 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841103750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007484868 | ||||||||
| FaxNumber: | 7707016676 | ||||||||
| Practice Location | |||||||||
| Address1: | 1485 S HIGHWAY 40 | ||||||||
| Address2: | |||||||||
| City: | HEBER CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840323522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356542500 | ||||||||
| FaxNumber: | 7707016676 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2008 | ||||||||
| LastUpdateDate: | 11/29/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | SL0585 | NV | N | Other Service Providers | Specialist | 207L00000X | 02003876A | IN | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 10498786-1204 | UT | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | P01424362 | 01 | IN | RAIL ROAD PTAN | OTHER |