Provider Demographics
NPI:1043400484
Name:MEDICAL IMAGING ASSOC OF IDAHO FALLS, PA
Entity Type:Organization
Organization Name:MEDICAL IMAGING ASSOC OF IDAHO FALLS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:M
Authorized Official - Last Name:HARRINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:424-218-9368
Mailing Address - Street 1:PO BOX 200338
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-0338
Mailing Address - Country:US
Mailing Address - Phone:208-715-5220
Mailing Address - Fax:
Practice Address - Street 1:3100 CHANNING WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7533
Practice Address - Country:US
Practice Address - Phone:208-227-2600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDICAL IMAGING ASSOCIATES OF IDAHO FALLS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-01
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty