Provider Demographics
NPI:1972500882
Name:SCOTT A ERICKSON MD, PC
Entity Type:Organization
Organization Name:SCOTT A ERICKSON MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:A
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-294-8288
Mailing Address - Street 1:440 MEDICAL DR
Mailing Address - Street 2:SUITE 4
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-4950
Mailing Address - Country:US
Mailing Address - Phone:801-294-8288
Mailing Address - Fax:801-294-8488
Practice Address - Street 1:440 MEDICAL DR
Practice Address - Street 2:SUITE 4
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-4950
Practice Address - Country:US
Practice Address - Phone:801-294-8288
Practice Address - Fax:801-294-8488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5836179-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000058051Medicare PIN
UTDF4190Medicare PIN