Healthcare Provider Details

I. General information

NPI: 1255345765
Provider Name (Legal Business Name): IDAHO INDEPENDENT MRI LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

562 SHOUP AVE W
TWIN FALLS ID
83301-5029
US

IV. Provider business mailing address

562 SHOUP AVE W
TWIN FALLS ID
83301-5029
US

V. Phone/Fax

Practice location:
  • Phone: 208-732-1205
  • Fax:
Mailing address:
  • Phone: 208-732-1205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0208X
TaxonomyMobile Radiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: FREDERICK L SURBAUGH
Title or Position: OWNER
Credential: MD
Phone: 208-732-1205