Provider Demographics
NPI:1922315084
Name:STEWART L ELLINGTON MD PC
Entity Type:Organization
Organization Name:STEWART L ELLINGTON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:STEWART
Authorized Official - Middle Name:L
Authorized Official - Last Name:ELLINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-364-5767
Mailing Address - Street 1:24 SOUTH1100 EAST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102
Mailing Address - Country:US
Mailing Address - Phone:801-364-5767
Mailing Address - Fax:801-531-9704
Practice Address - Street 1:24 SOUTH1100 EAST
Practice Address - Street 2:SUITE 103
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102
Practice Address - Country:US
Practice Address - Phone:801-364-5767
Practice Address - Fax:801-531-9704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-09
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT156919-1205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT240662791005Medicaid
UT000004964Medicare UPIN
UT240662791005Medicaid