Provider Demographics
NPI:1497712376
Name:SCOTT, KIM ELLEN (MD)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:ELLEN
Last Name:SCOTT
Suffix:
Gender:F
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:PO BOX 876
Mailing Address - Street 2:
Mailing Address - City:PRICE
Mailing Address - State:UT
Mailing Address - Zip Code:84501-0876
Mailing Address - Country:US
Mailing Address - Phone:435-613-9500
Mailing Address - Fax:435-613-9414
Practice Address - Street 1:1777 SUN PEAK DR
Practice Address - Street 2:SUITE 150
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-6725
Practice Address - Country:US
Practice Address - Phone:435-645-0800
Practice Address - Fax:435-647-3003
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT322406-1205207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D37616Medicare UPIN
UT005711201Medicare PIN