Provider Demographics
NPI:1265425029
Name:NORTH IDAHO MRI
Entity type:Organization
Organization Name:NORTH IDAHO MRI
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:LEGEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-666-2000
Mailing Address - Street 1:PO BOX 3103
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83816-2525
Mailing Address - Country:US
Mailing Address - Phone:208-666-3119
Mailing Address - Fax:208-666-3963
Practice Address - Street 1:825 W IRONWOOD DR
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2673
Practice Address - Country:US
Practice Address - Phone:208-666-3119
Practice Address - Fax:208-666-3963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-26
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010138805OtherIDAHO MEDICAID
ID84095OtherBLUE CROSS
ID002642800Medicaid
ID002642800Medicaid