1669732830 NPI number — UNIVERSITY OF UTAH NEUROSURGERY IMC

Table of content: (NPI 1669732830)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669732830 NPI number — UNIVERSITY OF UTAH NEUROSURGERY IMC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UNIVERSITY OF UTAH NEUROSURGERY IMC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669732830
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/22/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 413030
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84141-3030
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-213-3900
Provider Business Mailing Address Fax Number:
801-585-3655

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5171 COTTONWOOD ST
Provider Second Line Business Practice Location Address:
STE 945
Provider Business Practice Location Address City Name:
MURRAY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84107-5704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-507-9565
Provider Business Practice Location Address Fax Number:
801-507-9567
Provider Enumeration Date:
05/22/2012

Additional Information

Authorized Official

Authorized Official Last Name:
COULDWELL
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
T
Authorized Official Title or Position:
DEPT CHAIR
Authorized Official Telephone Number:
801-581-6908

Provider Taxonomy Codes

  • Taxonomy code: 207T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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