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General NPI Number Information
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NPI Number | 1932271624
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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 | 11/15/2006
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Last Update Date | 07/13/2011
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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 | 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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Authorized Official
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Title or Position | LABORATORY DIRECTOR
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Name | DR. ROBERT CZWALINA
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Credential | D.O.
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Telephone | 570-288-5441
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | 000495
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License Number State | PA
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