=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700093879
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEUROSURGERY & SPINE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2007
-----------------------------------------------------
Last Update Date | 06/09/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1220 E 3900 S STE 4E
-----------------------------------------------------
City | SALT LAKE CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84124-1343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-261-8507
-----------------------------------------------------
Fax | 801-261-8511
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1220 E 3900 S STE 4E
-----------------------------------------------------
City | SALT LAKE CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84124-1343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-261-8507
-----------------------------------------------------
Fax | 801-261-8511
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT CEO
-----------------------------------------------------
Name | DR. JAMES C PINGREE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 801-261-8507
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 344599-1205
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------