Provider Demographics
NPI:1336392448
Name:INTERMOUNTAIN ORTHOPAEDIC PLLC
Entity Type:Organization
Organization Name:INTERMOUNTAIN ORTHOPAEDIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:ARTHUR
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-383-0201
Mailing Address - Street 1:PO BOX 8886
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-8886
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 N. ROBBINS RD
Practice Address - Street 2:STE 401
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4539
Practice Address - Country:US
Practice Address - Phone:208-383-0201
Practice Address - Fax:208-489-4300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-03
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDDP2117OtherMEDICARE RR
ID88815OtherBLUECROSS
ID000010006178OtherBLUESHIELD
ID614389500OtherOWCP
ID88815OtherBLUECROSS
IDDP2117OtherMEDICARE RR