=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316128036
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAGE DIAGNOSTICS & IMAGING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2007
-----------------------------------------------------
Last Update Date | 11/21/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3875 E OVERLAND RD
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83642-9005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-287-6588
-----------------------------------------------------
Fax | 208-898-3950
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3875 E OVERLAND RD
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83642-9005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-287-6588
-----------------------------------------------------
Fax | 208-898-3950
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. TIMOTHY J JOHANS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 208-367-3500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1200X
-----------------------------------------------------
Taxonomy Name | Magnetic Resonance Imaging (MRI) Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------