Provider Demographics
NPI:1184754640
Name:SCOTT S EKDAHL
Entity type:Organization
Organization Name:SCOTT S EKDAHL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:S
Authorized Official - Last Name:EKDAHL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:928-636-4355
Mailing Address - Street 1:474 N HWY 89
Mailing Address - Street 2:
Mailing Address - City:CHINO VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86323-5993
Mailing Address - Country:US
Mailing Address - Phone:928-636-4355
Mailing Address - Fax:928-636-0754
Practice Address - Street 1:474 N HWY 89
Practice Address - Street 2:
Practice Address - City:CHINO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86323-5993
Practice Address - Country:US
Practice Address - Phone:928-636-4355
Practice Address - Fax:928-636-0754
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC2733207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ61972Medicare PIN