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General NPI Number Information
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NPI Number | 1356397673
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Entity Type | Organization
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Legal Business Name | INTERMOUNTAIN MEDICAL GROUP, INC
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Dates
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Enumeration Date | 05/26/2006
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Last Update Date | 01/25/2022
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Provider Practice Location Address
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Address Line | 610 WYOMING AVE
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City | KINGSTON
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State | PA
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Zip | 18704-3702
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Country | US
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Telephone | 570-288-5441
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Fax | 570-288-5842
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Provider Business Mailing Address
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Address Line | 4000 MERIDIAN BLVD
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City | FRANKLIN
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State | TN
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Zip | 37067-6325
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Country | US
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Telephone | 615-465-7000
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Fax | 615-628-6877
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Authorized Official
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Title or Position | SENIOR DIRECTOR PROVIDER ENROLLMENT
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Name | JENNIFER L JACKSON
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Credential |
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Telephone | 877-892-9815
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number |
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License Number State |
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Taxonomy #8
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number |
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License Number State |
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Taxonomy #9
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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Taxonomy #10
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number |
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License Number State | PA
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Taxonomy #11
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number |
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License Number State |
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Taxonomy #12
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #13
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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