Provider Demographics
NPI:1760810337
Name:INTERMOUNTAIN HEALTHCARE
Entity Type:Organization
Organization Name:INTERMOUNTAIN HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:GUDRUN
Authorized Official - Middle Name:ULRIKE
Authorized Official - Last Name:MIRIN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:801-408-8500
Mailing Address - Street 1:324 E 10TH AVE STE 178
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84103-2885
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:324 E 10TH AVE STE 178
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84103-2885
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:2013-10-17
Last Update Date:2013-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT932611213501302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization