Provider Demographics
NPI:1952377459
Name:RADIOLOGY PHYSICIANS OF IDAHO
Entity type:Organization
Organization Name:RADIOLOGY PHYSICIANS OF IDAHO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-233-1187
Mailing Address - Street 1:P.O. BOX 2580
Mailing Address - Street 2:1151 HOSPITAL WAY BLDG B
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201
Mailing Address - Country:US
Mailing Address - Phone:208-233-1187
Mailing Address - Fax:208-234-3841
Practice Address - Street 1:1151 HOSPITAL WAY BLDG B
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201
Practice Address - Country:US
Practice Address - Phone:208-233-1187
Practice Address - Fax:208-234-3841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-24
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002473400Medicaid
ID1371536Medicare UPIN
ID002473400Medicaid