MEDICARE: WESTERN NEUROLOGICAL ASSOCIATES INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist
2	2084N0402X	Neurology with Special Qualifications in Child Neurology Physician		UT
3	2085R0202X	Diagnostic Radiology Physician	0055926	UT
4	2084N0400X	Neurology Physician		UT

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	00055926	OTHER	UT	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083611966
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WESTERN NEUROLOGICAL ASSOCIATES INC

Provider Business Mailing Address
First Line	:	1151 E 3900 S
Second Line	:	#B150
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-1216
Country	:	US
Telephone Number	:	801-262-3441
Fax Number	:	801-269-9005

Provider Business Practice Location Address
First Line	:	1151 E 3900 S
Second Line	:	#B150
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-1216
Country	:	US
Telephone Number	:	801-262-3441
Fax Number	:	801-269-9005

Authorized Official
Title or Position	:	BUSINESS OFFICE
Name	:	MICHELLE LYNN HINES
Credential	:
Telephone Number	:	801-262-3441

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	07/21/2022

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