Provider Demographics
NPI:1457353450
Name:NORTH IDAHO IMAGING CENTER
Entity type:Organization
Organization Name:NORTH IDAHO IMAGING CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DELEGATED OFFICIAL
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:LEGEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-666-3200
Mailing Address - Street 1:PO BOX 1335
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83816-1335
Mailing Address - Country:US
Mailing Address - Phone:208-667-9334
Mailing Address - Fax:208-664-2341
Practice Address - Street 1:700 W IRONWOOD DR
Practice Address - Street 2:SUITE 110
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2656
Practice Address - Country:US
Practice Address - Phone:208-666-3200
Practice Address - Fax:208-666-3217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-10
Last Update Date:2009-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8J422OtherBC ID - PF
IDCR0440OtherRR MEDICARE
WA7058530Medicaid
ID86371OtherBC ID - CDA
ID002735600Medicaid
IDCR0440OtherRR MEDICARE