Healthcare Provider Details

I. General information

NPI: 1073079463
Provider Name (Legal Business Name): ALLIANCE MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2019
Last Update Date: 02/17/2025
Certification Date: 02/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512 N 21ST AVE
CALDWELL ID
83605-4368
US

IV. Provider business mailing address

PO BOX 191050
BOISE ID
83719-1050
US

V. Phone/Fax

Practice location:
  • Phone: 208-809-2875
  • Fax: 208-809-2876
Mailing address:
  • Phone: 208-955-6522
  • Fax: 208-955-6503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LINDA BARNES
Title or Position: CREDENTIALING MGR
Credential:
Phone: 208-985-1423