Provider Demographics
NPI:1205093739
Name:MOUNTAIN STATES ONCOLOGY GROUP
Entity type:Organization
Organization Name:MOUNTAIN STATES ONCOLOGY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JONI
Authorized Official - Middle Name:
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-343-3223
Mailing Address - Street 1:PO BOX 1809
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83701-1809
Mailing Address - Country:US
Mailing Address - Phone:208-343-3223
Mailing Address - Fax:208-343-3263
Practice Address - Street 1:210 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6044
Practice Address - Country:US
Practice Address - Phone:208-343-3223
Practice Address - Fax:208-343-3263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-21
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty