Healthcare Provider Details

I. General information

NPI: 1720181639
Provider Name (Legal Business Name): STEWART G CARRINGTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 12/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 S DAISY
SALMON ID
83467-0000
US

IV. Provider business mailing address

203 S. DAISY ST
SALMON ID
83467-0000
US

V. Phone/Fax

Practice location:
  • Phone: 208-756-5600
  • Fax: 208-756-4169
Mailing address:
  • Phone: 208-756-5600
  • Fax: 208-756-4169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberM-5749
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberM-5749
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: