1902835986 NPI number — INTERMOUNTAIN NEUROSURGERY, P.A.

Table of content: (NPI 1902835986)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902835986 NPI number — INTERMOUNTAIN NEUROSURGERY, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTERMOUNTAIN NEUROSURGERY, P.A.
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:
THE SPINE CENTER, P.A.
Provider Other Organization Name Type Code:
3
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:
1902835986
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 S 11TH AVE
Provider Second Line Business Mailing Address:
SUITE 504
Provider Business Mailing Address City Name:
POCATELLO
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83201-4835
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-233-8344
Provider Business Mailing Address Fax Number:
208-233-6983

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 S 11TH AVE
Provider Second Line Business Practice Location Address:
SUITE 504
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83201-4835
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-233-8344
Provider Business Practice Location Address Fax Number:
208-233-6983
Provider Enumeration Date:
07/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HUNEYCUTT
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
SCOTT
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
208-233-8344

Provider Taxonomy Codes

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

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





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