Healthcare Provider Details

I. General information

NPI: 1821458878
Provider Name (Legal Business Name): INTERMOUNTAIN SPINE PARTNERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2016
Last Update Date: 03/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5770 SOUTH 250 EAST SUITE 135
SALT LAKE CITY UT
84107-8241
US

IV. Provider business mailing address

5770 SOUTH 250 EAST SUITE 135
SALT LAKE CITY UT
84107-8241
US

V. Phone/Fax

Practice location:
  • Phone: 801-314-2225
  • Fax: 801-314-2345
Mailing address:
  • Phone: 801-314-2225
  • Fax: 801-314-2345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: REED EUGENE FOGG
Title or Position: DIRECTOR
Credential: M.D.
Phone: 801-314-2225