Basic Information
| Provider Information | |||||||||
| NPI: | 1225135106 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICAL NEUROSCIENCE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 N MEDICAL DR | ||||||||
| Address2: | U OF U SOM DEPT OF NEUROSURGERY #3B409 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841320001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015816909 | ||||||||
| FaxNumber: | 8015814385 | ||||||||
| Practice Location | |||||||||
| Address1: | 50 N MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841320001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015812121 | ||||||||
| FaxNumber: | 8015814385 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 09/06/2011 | ||||||||
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| AuthorizedOfficialLastName: | COULDWELL | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | DEPT CHAIR | ||||||||
| AuthorizedOfficialTelephone: | 8015816909 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2081P2900X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 118163700 | 05 | WY | MEDICAID | 806539400 | 05 | ID | MEDICAID | 100503241 | 05 | NV | MEDICAID |