Provider Demographics
NPI:1316128036
Name:SAGE DIAGNOSTICS & IMAGING
Entity type:Organization
Organization Name:SAGE DIAGNOSTICS & IMAGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:JOHANS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-367-3500
Mailing Address - Street 1:3875 E OVERLAND RD
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-9005
Mailing Address - Country:US
Mailing Address - Phone:208-287-6588
Mailing Address - Fax:208-898-3950
Practice Address - Street 1:3875 E OVERLAND RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-9005
Practice Address - Country:US
Practice Address - Phone:208-287-6588
Practice Address - Fax:208-898-3950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-21
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID261QM1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)