Healthcare Provider Details

I. General information

NPI: 1962493486
Provider Name (Legal Business Name): SCOTT RUSSELL BISHOP M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 08/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2038 W 1900 S
SYRACUSE UT
84075-9320
US

IV. Provider business mailing address

PO BOX 337
LAYTON UT
84041-0337
US

V. Phone/Fax

Practice location:
  • Phone: 801-773-4840
  • Fax: 801-926-1032
Mailing address:
  • Phone: 801-773-4840
  • Fax: 801-525-8151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number22441
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: