Provider Demographics
NPI:1962015776
Name:INNOVATIVE MEDICAL IMAGING, PLLC
Entity Type:Organization
Organization Name:INNOVATIVE MEDICAL IMAGING, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:STEPHAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:THIEDE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-334-7550
Mailing Address - Street 1:PO BOX 1614
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47706-0016
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:512 POLE LINE RD STE 1
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-6367
Practice Address - Country:US
Practice Address - Phone:208-735-5555
Practice Address - Fax:208-735-5556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-31
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty