Provider Demographics
NPI:1740551126
Name:R SCOTT BEVAN DPM PC
Entity type:Organization
Organization Name:R SCOTT BEVAN DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:BEVAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:801-243-3801
Mailing Address - Street 1:PO BOX 171258
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-1258
Mailing Address - Country:US
Mailing Address - Phone:801-243-3801
Mailing Address - Fax:
Practice Address - Street 1:965 E SOUTH UNION AVENUE
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-2323
Practice Address - Country:US
Practice Address - Phone:801-243-3801
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-18
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT92213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528725418002Medicaid
UTT89130Medicare UPIN
UT528725418002Medicaid