Provider Demographics
NPI:1417068271
Name:UNIVERSITY OF UTAH DIVISION OF PEDIATRIC NEUROSURGERY
Entity type:Organization
Organization Name:UNIVERSITY OF UTAH DIVISION OF PEDIATRIC NEUROSURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPT CHAIR
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:T
Authorized Official - Last Name:COULDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-581-6909
Mailing Address - Street 1:50 N MEDICAL DR
Mailing Address - Street 2:3B409-SOM
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84132-0001
Mailing Address - Country:US
Mailing Address - Phone:801-581-6909
Mailing Address - Fax:801-581-4385
Practice Address - Street 1:100 N MEDICAL DR
Practice Address - Street 2:SUITE 2400
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1103
Practice Address - Country:US
Practice Address - Phone:801-588-3400
Practice Address - Fax:801-588-3409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100389310AMedicaid
ID003073800Medicaid
WA7123755Medicaid
TXX9X042036Medicaid
NV100501144Medicaid
OK200019110AMedicaid
CO29584205Medicaid
NM837253Medicaid
WY116059100Medicaid
NM837253Medicaid
OK200019110AMedicaid