Basic Information
| Provider Information | |||||||||
| NPI: | 1417981234 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STOLWORTHY | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 25535 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8668987136 | ||||||||
| FaxNumber: | 6169759824 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 N 500 E | ||||||||
| Address2: | |||||||||
| City: | LOGAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4357161000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 11/15/2007 | ||||||||
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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 | 5110139 | UT | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | D4636 | 05 | UT | MEDICAID | P00000456 | 01 | RAILROAD MEDICARE | OTHER | 51101391200001 | 01 | BCBS | OTHER |