MEDICARE: INTERMOUNTAIN ALLERGY & IMMUNOLOGY CLINIC

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	207K00000X	Allergy & Immunology Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CO1561	OTHER		GROUP RAILROAD MEDICARE

General Provider Information

NPI Number	:	1972606036
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTERMOUNTAIN ALLERGY & IMMUNOLOGY CLINIC

Provider Business Mailing Address
First Line	:	6065 FASHION BLVD
Second Line	:	STE 255
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84107-7381
Country	:	US
Telephone Number	:	801-266-4115
Fax Number	:

Provider Business Practice Location Address
First Line	:	6065 FASHION BLVD
Second Line	:	STE 255
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84107-7381
Country	:	US
Telephone Number	:	801-266-4115
Fax Number	:

Authorized Official
Title or Position	:	PARTNER
Name	:	DUANE HARRIS
Credential	:
Telephone Number	:	801-363-4071

Provider Enumeration Date	:	09/06/2006
Last Update Date	:	01/11/2011

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