Provider Demographics
NPI:1114974953
Name:INTERMOUNTAIN MEDICAL IMAGING LLC
Entity Type:Organization
Organization Name:INTERMOUNTAIN MEDICAL IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:R
Authorized Official - Last Name:CLIFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-367-9060
Mailing Address - Street 1:PO BOX 9649
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83707-4649
Mailing Address - Country:US
Mailing Address - Phone:208-472-8101
Mailing Address - Fax:208-472-8172
Practice Address - Street 1:1055 N CURTIS RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1352
Practice Address - Country:US
Practice Address - Phone:208-367-2161
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1370119Medicare PIN