Provider Demographics
NPI:1669732830
Name:UNIVERSITY OF UTAH NEUROSURGERY IMC
Entity type:Organization
Organization Name:UNIVERSITY OF UTAH NEUROSURGERY IMC
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:801-581-6908
Mailing Address - Street 1:PO BOX 413030
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84141-3030
Mailing Address - Country:US
Mailing Address - Phone:801-213-3900
Mailing Address - Fax:801-585-3655
Practice Address - Street 1:5171 COTTONWOOD ST
Practice Address - Street 2:STE 945
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-5704
Practice Address - Country:US
Practice Address - Phone:801-507-9565
Practice Address - Fax:801-507-9567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-22
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty