Healthcare Provider Details

I. General information

NPI: 1396792305
Provider Name (Legal Business Name): SAWTOOTH DIAGNOSTIC IMAGING PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HOSPITAL DR.
KETCHUM ID
83340
US

IV. Provider business mailing address

PO BOX 9649
BOISE ID
83707-4649
US

V. Phone/Fax

Practice location:
  • Phone: 208-727-8205
  • Fax:
Mailing address:
  • Phone: 208-472-8125
  • 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 TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. LISA SMITH
Title or Position: ADMINISTRATOR
Credential:
Phone: 208-433-9466