Provider Demographics
NPI:1841393972
Name:INTERMOUNTAIN ALLERGY & IMMUNOLOGY CLINIC
Entity Type:Organization
Organization Name:INTERMOUNTAIN ALLERGY & IMMUNOLOGY CLINIC
Other - Org Name:INTERMOUNTAIN ALLERGY & ASTHMA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:DUANE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-363-4071
Mailing Address - Street 1:5929 FASHION POINT DR
Mailing Address - Street 2:STE 101
Mailing Address - City:SOUTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-4672
Mailing Address - Country:US
Mailing Address - Phone:801-476-0052
Mailing Address - Fax:801-476-0064
Practice Address - Street 1:5929 FASHION POINT DR
Practice Address - Street 2:STE 101
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4672
Practice Address - Country:US
Practice Address - Phone:801-476-0052
Practice Address - Fax:801-476-0064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DA3060OtherGROUP RAILROAD MEDICARE
000055069Medicare ID - Type UnspecifiedGROUP NUMBER