Provider Demographics
NPI:1578699039
Name:GRANT R FAIRBANKS MD PC
Entity Type:Organization
Organization Name:GRANT R FAIRBANKS MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:R
Authorized Official - Last Name:FAIRBANKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-268-8838
Mailing Address - Street 1:1151 EAST 3900 SOUTH
Mailing Address - Street 2:SUITE B110
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124
Mailing Address - Country:US
Mailing Address - Phone:801-268-8838
Mailing Address - Fax:801-268-8264
Practice Address - Street 1:1151 EAST 3900 SOUTH
Practice Address - Street 2:SUITE B110
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124
Practice Address - Country:US
Practice Address - Phone:801-268-8838
Practice Address - Fax:801-268-8264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1487731205208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000058179Medicare PIN
UT1578699039Medicare NSC