Provider Demographics
NPI:1235568130
Name:INTERMOUNTAIN HEALTHCARE
Entity Type:Organization
Organization Name:INTERMOUNTAIN HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-408-8500
Mailing Address - Street 1:LDS HOSPITAL 8TH AVE AND C ST
Mailing Address - Street 2:POB SUITE 172
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84143-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8TH AVENUE AND C ST
Practice Address - Street 2:LDS HOSPITAL
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84143
Practice Address - Country:US
Practice Address - Phone:801-408-8500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT278646282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
BC 5118511OtherDEA #