Provider Demographics
NPI:1124114038
Name:CARL KENT HEBDON MD PC
Entity type:Organization
Organization Name:CARL KENT HEBDON MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:KENT
Authorized Official - Last Name:HEBDON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-547-1991
Mailing Address - Street 1:PO BOX 1797
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-6797
Mailing Address - Country:US
Mailing Address - Phone:801-547-1991
Mailing Address - Fax:801-547-1929
Practice Address - Street 1:2040 MURRAY HOLLADAY RD
Practice Address - Street 2:SUITE 209
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-5185
Practice Address - Country:US
Practice Address - Phone:801-273-0306
Practice Address - Fax:801-273-0317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT160845-1205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT529602584001Medicaid
UT000059337Medicare PIN
UT000059336Medicare PIN