MEDICARE: INTERMOUNTAIN REHAB ASSOC IN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	29593	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1588772305
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTERMOUNTAIN REHAB ASSOC IN

Provider Business Mailing Address
First Line	:	559 E. PIKES PEAK AVE #100
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80903-3657
Country	:	US
Telephone Number	:	719-471-0727
Fax Number	:	719-471-2116

Provider Business Practice Location Address
First Line	:	559 E PIKES PEAK AVE #100
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80903-3657
Country	:	US
Telephone Number	:	719-471-0727
Fax Number	:	719-471-2116

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. TIMOTHY O. HALL
Credential	:	M.D.
Telephone Number	:	719-471-0727

Provider Enumeration Date	:	08/29/2006
Last Update Date	:	12/03/2007

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