MEDICARE: DAN HIBBERT UROLOGY, LLC

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	261QL0400X	Lithotripsy Clinic/Center	7100427-1205	UT
2	261QM2500X	Medical Specialty Clinic/Center	7100427-1205	UT

General Provider Information

NPI Number	:	1942448329
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DAN HIBBERT UROLOGY, LLC

Provider Business Mailing Address
First Line	:	11179 IVY CREEK CV
Second Line	:
City	:	SOUTH JORDAN
State	:	UT
Zip	:	84095-2249
Country	:	US
Telephone Number	:	801-822-2727
Fax Number	:

Provider Business Practice Location Address
First Line	:	4052 PIONEER PKWY
Second Line	:	#202
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84120-2062
Country	:	US
Telephone Number	:	801-955-4685
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	DR. DAN HIBBERT
Credential	:	MD
Telephone Number	:	801-822-2727

Provider Enumeration Date	:	01/23/2009
Last Update Date	:	09/27/2010

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