Basic Information
| Provider Information | |||||||||
| NPI: | 1669732830 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY OF UTAH NEUROSURGERY IMC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 413030 | ||||||||
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| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841413030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012133900 | ||||||||
| FaxNumber: | 8015853655 | ||||||||
| Practice Location | |||||||||
| Address1: | 5171 COTTONWOOD ST | ||||||||
| Address2: | STE 945 | ||||||||
| City: | MURRAY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841075704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015079565 | ||||||||
| FaxNumber: | 8015079567 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2012 | ||||||||
| LastUpdateDate: | 05/22/2012 | ||||||||
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| AuthorizedOfficialLastName: | COULDWELL | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | DEPT CHAIR | ||||||||
| AuthorizedOfficialTelephone: | 8015816908 | ||||||||
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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 | 207T00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |
No ID Information.