Healthcare Provider Details

I. General information

NPI: 1982037107
Provider Name (Legal Business Name): SJRMC INTERVENTIONAL RADIOLOGY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2013
Last Update Date: 03/24/2022
Certification Date: 03/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 6TH ST
LEWISTON ID
83501-2431
US

IV. Provider business mailing address

330 SEVEN SPRINGS WAY
BRENTWOOD TN
37027-5098
US

V. Phone/Fax

Practice location:
  • Phone: 208-750-7445
  • Fax: 208-750-7395
Mailing address:
  • Phone: 615-920-7000
  • Fax: 615-920-8775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number
License Number State

VIII. Authorized Official

Name: TERRANCE DILLON
Title or Position: ASST SECRETARY
Credential:
Phone: 615-920-7000