Provider Demographics
NPI:1215198031
Name:STONE CREEK FAMILY PRACTICE
Entity Type:Organization
Organization Name:STONE CREEK FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:BRET
Authorized Official - Last Name:CHIPMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-465-1555
Mailing Address - Street 1:910 E 100 N
Mailing Address - Street 2:STE 105
Mailing Address - City:PAYSON
Mailing Address - State:UT
Mailing Address - Zip Code:84651-1635
Mailing Address - Country:US
Mailing Address - Phone:801-465-1555
Mailing Address - Fax:801-465-1333
Practice Address - Street 1:910 E 100 N
Practice Address - Street 2:STE 105
Practice Address - City:PAYSON
Practice Address - State:UT
Practice Address - Zip Code:84651-1635
Practice Address - Country:US
Practice Address - Phone:801-465-1555
Practice Address - Fax:801-465-1333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-24
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5810651-1205208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528398932001Medicaid
000058003OtherMEDICAR GROUP
000058003OtherMEDICAR GROUP