Provider Demographics
NPI:1821280371
Name:MOUNTAIN TELERAD, PLLC
Entity Type:Organization
Organization Name:MOUNTAIN TELERAD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHEAL
Authorized Official - Middle Name:BRENT
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:208-455-7482
Mailing Address - Street 1:141 VICTOR GUST DR
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:ID
Mailing Address - Zip Code:83647-1654
Mailing Address - Country:US
Mailing Address - Phone:208-580-9524
Mailing Address - Fax:
Practice Address - Street 1:4519 ENTERPRISE WAY
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605
Practice Address - Country:US
Practice Address - Phone:208-455-7482
Practice Address - Fax:208-455-7538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-17
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistGroup - Single Specialty