Provider Demographics
NPI:1194843052
Name:PROVOST, SCOTT LYLES (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:LYLES
Last Name:PROVOST
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 1:3340 NORTH CENTER ST #800
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-7406
Mailing Address - Country:US
Mailing Address - Phone:801-990-1911
Mailing Address - Fax:
Practice Address - Street 1:5121 S COTTONWOOD STREET
Practice Address - Street 2:INTERMOUNTAIN MEDICAL CENTER
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84157
Practice Address - Country:US
Practice Address - Phone:801-507-5248
Practice Address - Fax:801-581-4367
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5210810-1205207L00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine