MEDICARE: INTERMOUNTAIN HEALTHCARE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM1300X	Multi-Specialty Clinic/Center	44723	UT

General Provider Information

NPI Number	:	1326096728
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTERMOUNTAIN HEALTHCARE

Provider Business Mailing Address
First Line	:	PO BOX 27128
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84127-0128
Country	:	US
Telephone Number	:	801-357-7291
Fax Number	:

Provider Business Practice Location Address
First Line	:	1055 N 300 W
Second Line	:	500
City	:	PROVO
State	:	UT
Zip	:	84604-3344
Country	:	US
Telephone Number	:	801-357-7291
Fax Number	:

Authorized Official
Title or Position	:	OPERATIONS DIRECTOR
Name	:	BRADY GILES
Credential	:
Telephone Number	:	801-357-2063

Provider Enumeration Date	:	05/05/2006
Last Update Date	:	08/22/2020

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Directions to “INTERMOUNTAIN HEALTHCARE ” Practice Location

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