MEDICARE: M R HINCKLEY MD PLLC

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	207ND0101X	MOHS-Micrographic Surgery Physician	76133041205	UT

General Provider Information

NPI Number	:	1902171895
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	M R HINCKLEY MD PLLC

Provider Business Mailing Address
First Line	:	602 FORT UNION BLVD
Second Line	:	2ND FLOOR
City	:	MIDVALE
State	:	UT
Zip	:	84047-2216
Country	:	US
Telephone Number	:	801-313-1010
Fax Number	:	801-747-2116

Provider Business Practice Location Address
First Line	:	602 FORT UNION BLVD
Second Line	:	2ND FLOOR
City	:	MIDVALE
State	:	UT
Zip	:	84047-2216
Country	:	US
Telephone Number	:	801-313-1010
Fax Number	:	801-747-2116

Authorized Official
Title or Position	:	OWNER
Name	:	MICHAEL RICHARD HINCKLEY
Credential	:	MD
Telephone Number	:	801-313-1010

Provider Enumeration Date	:	03/12/2012
Last Update Date	:	03/12/2012

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