Provider Demographics
NPI:1477540870
Name:INTERMOUNTAIN NEUROLOGY
Entity Type:Organization
Organization Name:INTERMOUNTAIN NEUROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:IMANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-475-7707
Mailing Address - Street 1:PO BOX 1512
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-6512
Mailing Address - Country:US
Mailing Address - Phone:801-593-9223
Mailing Address - Fax:801-593-9626
Practice Address - Street 1:6112 S 1550 E
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-5007
Practice Address - Country:US
Practice Address - Phone:801-475-7707
Practice Address - Fax:801-475-7322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT260615207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty