Provider Demographics
NPI:1821458878
Name:INTERMOUNTAIN SPINE PARTNERS
Entity Type:Organization
Organization Name:INTERMOUNTAIN SPINE PARTNERS
Other - Org Name:INTERMOUNTAIN SPINE INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:REED
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:FOGG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-314-2225
Mailing Address - Street 1:5770 SOUTH 250 EAST
Mailing Address - Street 2:SUITE 135
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-8241
Mailing Address - Country:US
Mailing Address - Phone:801-314-2225
Mailing Address - Fax:801-314-2345
Practice Address - Street 1:5770 SOUTH 250 EAST
Practice Address - Street 2:SUITE 135
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-8241
Practice Address - Country:US
Practice Address - Phone:801-314-2225
Practice Address - Fax:801-314-2345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-03
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty