Provider Demographics
NPI:1124258611
Name:GEM STATE RADIOLOGY LLP
Entity type:Organization
Organization Name:GEM STATE RADIOLOGY LLP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:BALDWIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-384-9060
Mailing Address - Street 1:877 W MAIN ST
Mailing Address - Street 2:SUITE 603
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-5883
Mailing Address - Country:US
Mailing Address - Phone:208-947-0100
Mailing Address - Fax:208-384-9023
Practice Address - Street 1:927 W MYRTLE ST STE B
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-7061
Practice Address - Country:US
Practice Address - Phone:208-947-0100
Practice Address - Fax:208-384-9023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-20
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805368800Medicaid