Healthcare Provider Details

I. General information

NPI: 1225135106
Provider Name (Legal Business Name): MEDICAL NEUROSCIENCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 09/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 N MEDICAL DR
SALT LAKE CITY UT
84132-0001
US

IV. Provider business mailing address

50 N MEDICAL DR U OF U SOM DEPT OF NEUROSURGERY #3B409
SALT LAKE CITY UT
84132-0001
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-2121
  • Fax: 801-581-4385
Mailing address:
  • Phone: 801-581-6909
  • Fax: 801-581-4385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. WILLIAM T COULDWELL
Title or Position: DEPT CHAIR
Credential: MD
Phone: 801-581-6909