Provider Demographics
NPI:1154584712
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:JEFFREY
Authorized Official - Middle Name:R
Authorized Official - Last Name:CLIFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-384-9060
Mailing Address - Street 1:877 W MAIN STREET
Mailing Address - Street 2:SUITE 603
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702
Mailing Address - Country:US
Mailing Address - Phone:208-384-9060
Mailing Address - Fax:208-384-9023
Practice Address - Street 1:161 E MALLARD DR
Practice Address - Street 2:SUITE 130
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-3974
Practice Address - Country:US
Practice Address - Phone:208-384-9060
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GEM STATE RADIOLOGY LLP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-03
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002874800Medicaid
ID002874800Medicaid