Provider Demographics
NPI:1972862605
Name:INTERMOUNTAIN PAIN MANAGEMENT AND INJURY, INC,
Entity Type:Organization
Organization Name:INTERMOUNTAIN PAIN MANAGEMENT AND INJURY, INC,
Other - Org Name:INTERMOUNTAIN PAIN AND INJURY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:EDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-510-1538
Mailing Address - Street 1:6575 S REDWOOD RD
Mailing Address - Street 2:ST 201
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84123-5688
Mailing Address - Country:US
Mailing Address - Phone:801-262-9600
Mailing Address - Fax:
Practice Address - Street 1:6575 S REDWOOD RD
Practice Address - Street 2:ST 201
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84123-5688
Practice Address - Country:US
Practice Address - Phone:801-262-9600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-15
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty