Provider Demographics
NPI:1700011954
Name:ERICA A. FAIRCLOTH, M.D., P.C.
Entity Type:Organization
Organization Name:ERICA A. FAIRCLOTH, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:A
Authorized Official - Last Name:FAIRCLOTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PC
Authorized Official - Phone:801-261-3975
Mailing Address - Street 1:3970 S 700 E
Mailing Address - Street 2:SUITE 14
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-2191
Mailing Address - Country:US
Mailing Address - Phone:801-261-3975
Mailing Address - Fax:801-262-9142
Practice Address - Street 1:3970 S 700 E
Practice Address - Street 2:SUITE 14
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-2191
Practice Address - Country:US
Practice Address - Phone:801-261-3975
Practice Address - Fax:801-262-9142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-18
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7256620-1205207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1689849523Medicaid