Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207T00000X | Neurosurgeon | 12439568-1205 | UT |
NPI | 1093343527 |
---|---|
Provider Name | Michael T. Bounajem |
First Address | Salt Lake City, UT 84132-0001 |
Second Address | Salt Lake City, UT 84132-0001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/03/2020 |
Last Update Date | 17/09/2021 |