Healthcare Provider Details

I. General information

NPI: 1558304329
Provider Name (Legal Business Name): INTERMOUNTAIN ANESTHESIA, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 07/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 CHANNING WAY
IDAHO FALLS ID
83404-7533
US

IV. Provider business mailing address

PO BOX 94289, MS 631130
SEATTLE WA
98124-6589
US

V. Phone/Fax

Practice location:
  • Phone: 208-529-6269
  • Fax:
Mailing address:
  • Phone: 866-487-0277
  • Fax: 770-701-6674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY TAYLOR
Title or Position: CRNA
Credential:
Phone: 866-487-0277