NPIMap

Organization Active NPI

Oculoplastic Surgery, Inc.

Doing business as Still Canyon Eyelid & Facial Plastic Surgery

  • Ophthalmic Plastic and Reconstructive Surgery Physician
  • Holladay, UT
National Provider Identifier
1578780805
Registry record updated Sep 29, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Ophthalmic Plastic and Reconstructive Surgery PhysicianTaxonomy code 207WX0200X
Legal business name
OCULOPLASTIC SURGERY, INC.
Doing business as
Still Canyon Eyelid & Facial Plastic Surgery
Practice address
5200 S Highland Dr Ste 201
Holladay, UT 84117-7003
Phone
(801) 363-3356
Fax
(801) 533-9613
NPI assigned
Apr 19, 2007
Last updated
Sep 29, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 29, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Thomas J J Oberg, MDNPI 1801021126
Title
Provider/Owner
Phone
(801) 363-3356

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Ophthalmic Plastic and Reconstructive Surgery PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207WX0200X Primary

Addresses

Primary practice location

5200 S Highland Dr Ste 201
Holladay, UT 84117-7003

Mailing address

5200 S Highland Dr Ste 201
Holladay, UT 84117-7003
Phone (801) 363-3356

Other identifiers 3

IdentifierTypeStateIssuer
479544679030MedicaidUT
464491680001MedicaidUT
485924851015MedicaidUT

Other names 1

  • Still Canyon Eyelid & Facial Plastic Surgery Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in UT

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040526001234 UT Part B Supplier - Clinic/Group Practice 5799766671 Receives reassigned benefits from 2 practitioners
Practice locations: Holladay, UT; Salt Lake City, UT

National Provider Directory

National Provider Directory

Locations

5200 S Highland Dr
Ste 201
Salt Lake City, UT 84117
Phone (801) 363-3356

1002 E South Temple
Ste 308
Salt Lake Cty, UT 84102
Phone (801) 363-3355

9350 S 150 E
Ofc
Sandy, UT 84070
Phone (801) 363-3355

Practitioners & affiliated clinicians

Practitioners 11

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1176940800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1695945600000",
    "number": "1578780805",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5200 S HIGHLAND DR STE 201",
            "city": "HOLLADAY",
            "state": "UT",
            "postal_code": "841177003",
            "telephone_number": "801-363-3356",
            "fax_number": "801-533-9613"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5200 S HIGHLAND DR STE 201",
            "city": "HOLLADAY",
            "state": "UT",
            "postal_code": "841177003",
            "telephone_number": "801-363-3356",
            "fax_number": "801-533-9613"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "OCULOPLASTIC SURGERY, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-04-19",
        "last_updated": "2023-09-29",
        "certification_date": "2023-09-29",
        "status": "A",
        "authorized_official_last_name": "OBERG",
        "authorized_official_first_name": "THOMAS",
        "authorized_official_middle_name": "J J",
        "authorized_official_title_or_position": "PROVIDER/OWNER",
        "authorized_official_telephone_number": "801-363-3356",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207WX0200X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Ophthalmology, Ophthalmic Plastic and Reconstructive Surgery",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "479544679030",
            "state": "UT"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "464491680001",
            "state": "UT"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "485924851015",
            "state": "UT"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Still Canyon Eyelid & Facial Plastic Surgery",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Holladay, UT

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 29, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.