Provider Demographics
NPI:1699940346
Name:SPINEIDAHO PLLC
Entity type:Organization
Organization Name:SPINEIDAHO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:HUNEYCUTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-233-8344
Mailing Address - Street 1:2240 E CENTER STREET
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201
Mailing Address - Country:US
Mailing Address - Phone:208-233-8344
Mailing Address - Fax:208-233-6983
Practice Address - Street 1:2240 E CENTER ST
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201
Practice Address - Country:US
Practice Address - Phone:208-233-8344
Practice Address - Fax:208-233-6983
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-24
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1370097Medicare PIN
ID6241880001Medicare NSC