Provider Demographics
NPI:1386750859
Name:MOUNTAIN STATES ONCOLOGY GROUP
Entity type:Organization
Organization Name:MOUNTAIN STATES ONCOLOGY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS ADMINSTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JONI
Authorized Official - Middle Name:
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-343-3223
Mailing Address - Street 1:PO BOX 1809
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83701-1809
Mailing Address - Country:US
Mailing Address - Phone:208-343-3223
Mailing Address - Fax:
Practice Address - Street 1:100 E IDAHO ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6223
Practice Address - Country:US
Practice Address - Phone:208-343-3223
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty