Provider Demographics
NPI:1598524696
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:WAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:BALDWIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-384-9060
Mailing Address - Street 1:877 W MAIN ST STE 603
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6070
Mailing Address - Country:US
Mailing Address - Phone:208-991-5212
Mailing Address - Fax:
Practice Address - Street 1:875 S VANGUARD WAY STE 100
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-8541
Practice Address - Country:US
Practice Address - Phone:208-954-8100
Practice Address - Fax:208-947-3322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-19
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty