Provider Demographics
NPI:1891008777
Name:GRANT A. FAIRBANKS, MD PC
Entity type:Organization
Organization Name:GRANT A. FAIRBANKS, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:A
Authorized Official - Last Name:FAIRBANKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-701-8688
Mailing Address - Street 1:PO BOX 1071
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84011-1071
Mailing Address - Country:US
Mailing Address - Phone:801-701-8688
Mailing Address - Fax:801-701-8689
Practice Address - Street 1:520 MEDICAL DR
Practice Address - Street 2:SUITE 210
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-4968
Practice Address - Country:US
Practice Address - Phone:801-268-8838
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-20
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2744901205208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTI50103Medicare UPIN