Provider Demographics
NPI:1316117567
Name:BOUNTIFUL SURGICAL ASSOCIATES
Entity type:Organization
Organization Name:BOUNTIFUL SURGICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:H
Authorized Official - Last Name:TODD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-298-1123
Mailing Address - Street 1:425 MEDICAL DRIVE #101
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010
Mailing Address - Country:US
Mailing Address - Phone:801-298-1123
Mailing Address - Fax:801-292-1271
Practice Address - Street 1:425 MEDICAL DRIVE #101
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010
Practice Address - Country:US
Practice Address - Phone:801-298-1123
Practice Address - Fax:801-292-1271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-04
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty