Provider Demographics
NPI:1902835986
Name:INTERMOUNTAIN NEUROSURGERY, P.A.
Entity Type:Organization
Organization Name:INTERMOUNTAIN NEUROSURGERY, P.A.
Other - Org Name:THE SPINE CENTER, P.A.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:HUNEYCUTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-233-8344
Mailing Address - Street 1:500 S 11TH AVE
Mailing Address - Street 2:SUITE 504
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4835
Mailing Address - Country:US
Mailing Address - Phone:208-233-8344
Mailing Address - Fax:208-233-6983
Practice Address - Street 1:500 S 11TH AVE
Practice Address - Street 2:SUITE 504
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4835
Practice Address - Country:US
Practice Address - Phone:208-233-8344
Practice Address - Fax:208-233-6983
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1377746Medicare ID - Type Unspecified
ID5632250001Medicare NSC