MEDICARE: MR. ERIC WILLIAM STEPHAN MSPT

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	225100000X	Physical Therapist	PT00008288	WA

General Provider Information

NPI Number	:	1295729432
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ERIC WILLIAM STEPHAN MSPT

Provider Business Mailing Address
First Line	:	702 E 400 S
Second Line	:
City	:	CLEARFIELD
State	:	UT
Zip	:	84015-1108
Country	:	US
Telephone Number	:	801-309-8807
Fax Number	:	801-586-9741

Provider Business Practice Location Address
First Line	:	7321 11TH ST
Second Line	:
City	:	HILL AFB
State	:	UT
Zip	:	84056-5012
Country	:	US
Telephone Number	:	801-777-5400
Fax Number	:	801-586-9741

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

Provider Enumeration Date	:	09/02/2005
Last Update Date	:	07/08/2007

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