Provider Demographics
NPI:1073546289
Name:INTERMOUNTAIN AMBULATORY ANESTHESIA PLLC
Entity type:Organization
Organization Name:INTERMOUNTAIN AMBULATORY ANESTHESIA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-960-0870
Mailing Address - Street 1:PO BOX 3661
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-3661
Mailing Address - Country:US
Mailing Address - Phone:800-475-6236
Mailing Address - Fax:
Practice Address - Street 1:875 S VANGUARD WAY
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-8540
Practice Address - Country:US
Practice Address - Phone:208-373-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806036500Medicaid
ID1377728Medicare PIN