=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255570453
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHEPARD CREEK OB-GYN, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2009
-----------------------------------------------------
Last Update Date | 01/07/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 670 SHEPARD LN STE 103
-----------------------------------------------------
City | FARMINGTON
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84025-3936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-447-3377
-----------------------------------------------------
Fax | 801-447-3442
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 670 SHEPARD LN STE 103
-----------------------------------------------------
City | FARMINGTON
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84025-3936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-447-3377
-----------------------------------------------------
Fax | 801-447-3442
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. NEIL O SPENCER
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 801-447-3377
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 891804611205
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------