Healthcare Provider Details

I. General information

NPI: 1700644812
Provider Name (Legal Business Name): ALLIANCE MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2024
Last Update Date: 02/17/2025
Certification Date: 02/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 S VANGUARD WAY STE 200A
MERIDIAN ID
83642-9445
US

IV. Provider business mailing address

PO BOX 191050
BOISE ID
83719-1050
US

V. Phone/Fax

Practice location:
  • Phone: 208-809-2895
  • Fax: 208-809-2896
Mailing address:
  • Phone: 208-955-6500
  • Fax: 208-955-6503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State

VIII. Authorized Official

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