Provider Demographics
NPI:1013058395
Name:IHC HEALTH SERVICE INC
Entity Type:Organization
Organization Name:IHC HEALTH SERVICE INC
Other - Org Name:INTERMOUNTAIN EPHRAIM CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO - INTERMOUNTAIN MEDICAL GROUP
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:C
Authorized Official - Last Name:LECKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-442-3974
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:435-283-4076
Mailing Address - Fax:435-283-4078
Practice Address - Street 1:525 N MAIN ST
Practice Address - Street 2:
Practice Address - City:EPHRAIM
Practice Address - State:UT
Practice Address - Zip Code:84627-1155
Practice Address - Country:US
Practice Address - Phone:435-283-4076
Practice Address - Fax:435-283-4078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1195207Q00000X, 207X00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000055456Medicare PIN