MEDICARE: DR. STEPHAN L RALSTON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208200000X	Plastic Surgery Physician	1648361205	UT

General Provider Information

NPI Number	:	1538237375
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STEPHAN L RALSTON M.D.

Provider Business Mailing Address
First Line	:	1452 E RIDGELINE DR
Second Line	:	SUITE 100
City	:	SOUTH OGDEN
State	:	UT
Zip	:	84405-4946
Country	:	US
Telephone Number	:	801-479-5937
Fax Number	:	801-479-5917

Provider Business Practice Location Address
First Line	:	1452 E RIDGELINE DR
Second Line	:	SUITE 100
City	:	SOUTH OGDEN
State	:	UT
Zip	:	84405-4946
Country	:	US
Telephone Number	:	801-479-5937
Fax Number	:	801-479-5917

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/01/2006
Last Update Date	:	07/09/2007

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