Provider Demographics
NPI:1144420357
Name:FREDRICKSON, SCOTT HARTLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:HARTLEY
Last Name:FREDRICKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 S 500 E
Mailing Address - Street 2:
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1907
Mailing Address - Country:US
Mailing Address - Phone:801-463-7415
Mailing Address - Fax:
Practice Address - Street 1:144 S 500 E
Practice Address - Street 2:
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84102-1907
Practice Address - Country:US
Practice Address - Phone:801-463-7415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-25
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7536320-1205207P00000X
CAA106215207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine