Provider Demographics
NPI:1346410073
Name:WASATCH NEUROLOGICAL SURGERY PC
Entity Type:Organization
Organization Name:WASATCH NEUROLOGICAL SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:CLYDE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-295-2438
Mailing Address - Street 1:3401 S HIGHWAY 89
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-8517
Mailing Address - Country:US
Mailing Address - Phone:801-295-2438
Mailing Address - Fax:866-630-0782
Practice Address - Street 1:3401 S HIGHWAY 89
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-8517
Practice Address - Country:US
Practice Address - Phone:801-295-2438
Practice Address - Fax:866-630-0782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-10
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT48219121205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTG52536Medicare UPIN
UT000058023Medicare PIN