Provider Demographics
NPI:1821036724
Name:INTERMOUNTAIN SPINE AND ORTHOPEDICS, PC
Entity Type:Organization
Organization Name:INTERMOUNTAIN SPINE AND ORTHOPEDICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:M
Authorized Official - Last Name:CHRISTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-732-0067
Mailing Address - Street 1:1411 FALLS AVE E STE 1301
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3467
Mailing Address - Country:US
Mailing Address - Phone:208-732-0067
Mailing Address - Fax:208-732-3195
Practice Address - Street 1:1411 FALLS AVE E
Practice Address - Street 2:SUITE 1301
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3455
Practice Address - Country:US
Practice Address - Phone:208-732-0067
Practice Address - Fax:208-732-3195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010148684OtherBLUE SHIELD
IDDC8006OtherRR MEDICARE
ID8J828OtherBLUE CROSS
ID807012500Medicaid
ID807012500Medicaid
ID5285790002Medicare NSC