Provider Demographics
NPI:1417737594
Name:MOMENTUM MEDICAL GROUP OF IDAHO LLC
Entity Type:Organization
Organization Name:MOMENTUM MEDICAL GROUP OF IDAHO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SERVICE
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:BEARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-880-0883
Mailing Address - Street 1:8854 W EMERALD ST STE 140
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-4845
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8854 W EMERALD ST STE 275
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-4860
Practice Address - Country:US
Practice Address - Phone:208-375-3201
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-04
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty