Provider Demographics
NPI:1366654535
Name:STANSBURY PEDIATRICS, INC
Entity Type:Organization
Organization Name:STANSBURY PEDIATRICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:S
Authorized Official - Last Name:MCMILLAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-882-1288
Mailing Address - Street 1:PO BOX 932
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84091-0932
Mailing Address - Country:US
Mailing Address - Phone:801-553-9568
Mailing Address - Fax:801-553-9562
Practice Address - Street 1:210 MILLPOND
Practice Address - Street 2:
Practice Address - City:STANSBURY PARK
Practice Address - State:UT
Practice Address - Zip Code:84074
Practice Address - Country:US
Practice Address - Phone:435-882-1288
Practice Address - Fax:435-882-1275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5904241-12052080H0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080H0002XAllopathic & Osteopathic PhysiciansPediatricsHospice and Palliative MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT022588131001Medicaid
UTI52199Medicare UPIN