Basic Information
| Provider Information | |||||||||
| NPI: | 1902835986 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTERMOUNTAIN NEUROSURGERY, P.A. | ||||||||
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| OtherOrganizationName: | THE SPINE CENTER, P.A. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 S 11TH AVE | ||||||||
| Address2: | SUITE 504 | ||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832014835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082338344 | ||||||||
| FaxNumber: | 2082336983 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 S 11TH AVE | ||||||||
| Address2: | SUITE 504 | ||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832014835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082338344 | ||||||||
| FaxNumber: | 2082336983 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2006 | ||||||||
| LastUpdateDate: | 03/17/2008 | ||||||||
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| AuthorizedOfficialLastName: | HUNEYCUTT | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | SCOTT | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2082338344 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | ID | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |
No ID Information.