=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356447452
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SCOTT E. FAULKNER, M.D., PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2006
-----------------------------------------------------
Last Update Date | 02/14/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 MAIN ST
-----------------------------------------------------
City | FORT MORGAN
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80701-2130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-542-0360
-----------------------------------------------------
Fax | 970-542-0366
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 117
-----------------------------------------------------
City | FORT MORGAN
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80701-0117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-542-0360
-----------------------------------------------------
Fax | 970-542-0366
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. SCOTT E FAULKNER
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 970-542-0360
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 39644
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------