Healthcare Provider Details

I. General information

NPI: 1174932966
Provider Name (Legal Business Name): WENDELL TODD SHRUM RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2014
Last Update Date: 08/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1360 E 5360 S
MURRAY UT
84117-7361
US

IV. Provider business mailing address

1360 E 5360 S
MURRAY UT
84117-7361
US

V. Phone/Fax

Practice location:
  • Phone: 205-305-6251
  • Fax:
Mailing address:
  • Phone: 205-305-6251
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License Number6949270-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: