Healthcare Provider Details

I. General information

NPI: 1215973169
Provider Name (Legal Business Name): IDAHO RADIOLOGY ASSOCIATES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 07/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2035 SILVERCREEK LN
BOISE ID
83706-6112
US

IV. Provider business mailing address

PO BOX 9649
BOISE ID
83707-4649
US

V. Phone/Fax

Practice location:
  • Phone: 208-368-0095
  • Fax:
Mailing address:
  • Phone: 208-472-8119
  • Fax: 208-344-1926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DIANE NEWTON
Title or Position: OWNER
Credential: M.D.
Phone: 208-368-0095