Provider Demographics
NPI:1154429058
Name:INTERMOUNTAIN DIAGNOSTICS, INC.
Entity type:Organization
Organization Name:INTERMOUNTAIN DIAGNOSTICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING AGENT
Authorized Official - Prefix:
Authorized Official - First Name:L. KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMMACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-337-4254
Mailing Address - Street 1:200 N 4TH ST
Mailing Address - Street 2:SUITE 15
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6001
Mailing Address - Country:US
Mailing Address - Phone:208-331-0436
Mailing Address - Fax:208-424-8501
Practice Address - Street 1:200 N 4TH ST
Practice Address - Street 2:SUITE 15
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6001
Practice Address - Country:US
Practice Address - Phone:208-331-0436
Practice Address - Fax:208-424-8501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNONE GIVEN IN IDAHO246XS1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246XS1301XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist CardiovascularSonographyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010017912OtherBLUE SHIELD
ID170283OtherOMAP (OREGON MEDICAL)
ID8D244OtherBLUE CROSS
ID1538377OtherUNITED MINE WORKERS
ID8D244OtherBLUE CROSS