Basic Information
| Provider Information | |||||||||
| NPI: | 1316993520 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | STANLEY | ||||||||
| MiddleName: | DWAYNE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10 | ||||||||
| Address2: | |||||||||
| City: | SPANISH FORK | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846600010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8668987136 | ||||||||
| FaxNumber: | 6169759824 | ||||||||
| Practice Location | |||||||||
| Address1: | 118 N MAIN ST | ||||||||
| Address2: | STE B | ||||||||
| City: | SALEM | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846535698 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014779007 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 05/09/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | 276489 | UT | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 207QS0010X | 276489-1205 | UT | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 107018542102 | 01 | UT | SELECT HEALTH | OTHER | 174069 | 01 | UT | DESERET MUTUAL | OTHER | 87148 | 01 | UT | PEHP | OTHER | 52892628603001 | 01 | BCBS | OTHER | D1423 | 05 | UT | MEDICAID | P00221212 | 01 | RAILROAD MEDICARE | OTHER |