Provider Demographics
NPI:1427456797
Name:INTERMOUNTAIN HEALTHCARE
Entity type:Organization
Organization Name:INTERMOUNTAIN HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ATHLETIC TRAINER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:TERRY
Authorized Official - Suffix:
Authorized Official - Credentials:ATC
Authorized Official - Phone:435-251-3600
Mailing Address - Street 1:652 S MEDICAL CENTER DR
Mailing Address - Street 2:SUITE 120
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-7049
Mailing Address - Country:US
Mailing Address - Phone:435-251-3600
Mailing Address - Fax:435-628-4469
Practice Address - Street 1:652 S MEDICAL CENTER DR
Practice Address - Street 2:SUITE 120
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-7049
Practice Address - Country:US
Practice Address - Phone:435-251-3600
Practice Address - Fax:435-628-4469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-18
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8207030-4810207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty