Provider Demographics
NPI:1508875360
Name:DIAGNOSTIC IMAGING SERVICE OF IDAHO
Entity Type:Organization
Organization Name:DIAGNOSTIC IMAGING SERVICE OF IDAHO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:EVERSON
Authorized Official - Suffix:
Authorized Official - Credentials:RDMS
Authorized Official - Phone:208-237-0977
Mailing Address - Street 1:1951 BENCH RD
Mailing Address - Street 2:SUITE F
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2073
Mailing Address - Country:US
Mailing Address - Phone:208-237-0977
Mailing Address - Fax:208-237-0985
Practice Address - Street 1:1951 BENCH RD
Practice Address - Street 2:SUITE F
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2073
Practice Address - Country:US
Practice Address - Phone:208-237-0977
Practice Address - Fax:208-237-0985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-07
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiographyGroup - Multi-Specialty
No261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, MobileGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID804301300Medicaid
ID804301300Medicaid