Provider Demographics
NPI:1912347451
Name:INTERMOUNTAIN HEALTH CARE
Entity Type:Organization
Organization Name:INTERMOUNTAIN HEALTH CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:MINER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-314-4500
Mailing Address - Street 1:5770 S 250 E STE 310
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-8110
Mailing Address - Country:US
Mailing Address - Phone:801-314-4500
Mailing Address - Fax:801-314-2909
Practice Address - Street 1:5770 S 250 E STE 310
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-8110
Practice Address - Country:US
Practice Address - Phone:801-314-4500
Practice Address - Fax:801-314-2909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-28
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT195697-3102174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth EducatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000055456OtherINTERMOUNTAIN MEDICAL GROUP