MEDICARE: SCOTT S EKDAHL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	OTC2733	AZ

General Provider Information

NPI Number	:	1184754640
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SCOTT S EKDAHL

Provider Business Mailing Address
First Line	:	474 N HWY 89
Second Line	:
City	:	CHINO VALLEY
State	:	AZ
Zip	:	86323-5993
Country	:	US
Telephone Number	:	928-636-4355
Fax Number	:	928-636-0754

Provider Business Practice Location Address
First Line	:	474 N HWY 89
Second Line	:
City	:	CHINO VALLEY
State	:	AZ
Zip	:	86323-5993
Country	:	US
Telephone Number	:	928-636-4355
Fax Number	:	928-636-0754

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	DR. SCOTT S EKDAHL
Credential	:	DO
Telephone Number	:	928-636-4355

Provider Enumeration Date	:	03/06/2007
Last Update Date	:	07/19/2012

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