Provider Demographics
NPI:1831423557
Name:IDAGEM SERVICES INC
Entity type:Organization
Organization Name:IDAGEM SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KRAWTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-283-6678
Mailing Address - Street 1:1533 N MILWAUKEE ST
Mailing Address - Street 2:STE 321
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8471
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1533 N MILWAUKEE ST
Practice Address - Street 2:STE 321
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8471
Practice Address - Country:US
Practice Address - Phone:208-283-6678
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-28
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM9083207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty