Healthcare Provider Details

I. General information

NPI: 1427456797
Provider Name (Legal Business Name): INTERMOUNTAIN HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2014
Last Update Date: 12/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

652 S MEDICAL CENTER DR SUITE 120
ST GEORGE UT
84790-7049
US

IV. Provider business mailing address

652 S MEDICAL CENTER DR SUITE 120
ST GEORGE UT
84790-7049
US

V. Phone/Fax

Practice location:
  • Phone: 435-251-3600
  • Fax: 435-628-4469
Mailing address:
  • Phone: 435-251-3600
  • Fax: 435-628-4469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number8207030-4810
License Number StateUT

VIII. Authorized Official

Name: JENNIFER LEE TERRY
Title or Position: ATHLETIC TRAINER
Credential: ATC
Phone: 435-251-3600