Basic Information
Provider Information | |||||||||
NPI: | 1417978198 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MARBLE | ||||||||
FirstName: | STEPHEN | ||||||||
MiddleName: | P | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 307 | ||||||||
Address2: |   | ||||||||
City: | BOUNTIFUL | ||||||||
State: | UT | ||||||||
PostalCode: | 840110307 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8887006907 | ||||||||
FaxNumber: | 8012946917 | ||||||||
Practice Location | |||||||||
Address1: | 8074 S 1300 E | ||||||||
Address2: |   | ||||||||
City: | SANDY | ||||||||
State: | UT | ||||||||
PostalCode: | 840940743 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8015656500 | ||||||||
FaxNumber: | 8015656501 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/21/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 187819-1205 | UT | Y |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   |
ID Information
ID | Type | State | Issuer | Description | 2600404994002 | 05 | UT |   | MEDICAID |