Healthcare Provider Details

I. General information

NPI: 1902835986
Provider Name (Legal Business Name): INTERMOUNTAIN NEUROSURGERY, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 03/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S 11TH AVE SUITE 504
POCATELLO ID
83201-4835
US

IV. Provider business mailing address

500 S 11TH AVE SUITE 504
POCATELLO ID
83201-4835
US

V. Phone/Fax

Practice location:
  • Phone: 208-233-8344
  • Fax: 208-233-6983
Mailing address:
  • Phone: 208-233-8344
  • Fax: 208-233-6983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number StateID

VIII. Authorized Official

Name: WILLIAM SCOTT HUNEYCUTT
Title or Position: PRESIDENT
Credential: M.D.
Phone: 208-233-8344