Basic Information
| Provider Information | |||||||||
| NPI: | 1932156692 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEDLIN | ||||||||
| FirstName: | WALTER | ||||||||
| MiddleName: | SCOTT EDWARDS | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1046 E 100 S | ||||||||
| Address2: | SUITE A | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841021520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4066942487 | ||||||||
| FaxNumber: | 8017462886 | ||||||||
| Practice Location | |||||||||
| Address1: | 1046 E 100 S | ||||||||
| Address2: | SUITE A | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841021520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4066942487 | ||||||||
| FaxNumber: | 8017462886 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2006 | ||||||||
| LastUpdateDate: | 08/21/2014 | ||||||||
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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 | 208600000X | 47825-020 | WI | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | MD00037282 | WA | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 12854 | MT | Y | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 8984752-1205 | UT | N | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 7762232 | 01 | WA | AETNA | OTHER | 0248634 | 01 | WA | L&I AND CRIME VICTIMS | OTHER | 1932156692 | 05 | WA | MEDICAID | 976488700 | 05 | MN | MEDICAID | MD0608W | 05 | AK | MEDICAID | 1008ME | 01 | WA | REGENCE | OTHER |