Provider Demographics
NPI:1225135106
Name:MEDICAL NEUROSCIENCE
Entity Type:Organization
Organization Name:MEDICAL NEUROSCIENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPT CHAIR
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:T
Authorized Official - Last Name:COULDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-581-6909
Mailing Address - Street 1:50 N MEDICAL DR
Mailing Address - Street 2:U OF U SOM DEPT OF NEUROSURGERY #3B409
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84132-0001
Mailing Address - Country:US
Mailing Address - Phone:801-581-6909
Mailing Address - Fax:801-581-4385
Practice Address - Street 1:50 N MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0001
Practice Address - Country:US
Practice Address - Phone:801-581-2121
Practice Address - Fax:801-581-4385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY118163700Medicaid
ID806539400Medicaid
NV100503241Medicaid
UT=========006Medicaid
NV100503241Medicaid