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General NPI Number Information
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NPI Number | 1669423679
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Entity Type | Organization
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Legal Business Name | INTERMOUNTAIN MEDICAL IMAGING LLC
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Dates
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Enumeration Date | 05/15/2006
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Last Update Date | 10/31/2023
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Provider Practice Location Address
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Address Line | 927 W MYRTLE ST
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City | BOISE
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State | ID
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Zip | 83702-7061
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Country | US
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Telephone | 208-367-7510
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Fax | 208-367-6367
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Provider Business Mailing Address
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Address Line | 877 W MAIN ST STE 603
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City | BOISE
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State | ID
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Zip | 83702-6070
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Country | US
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Telephone | 208-954-8175
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Fax | 208-384-9023
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. WAYNE BALDWIN
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Credential |
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Telephone | 208-384-9060
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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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