Basic Information
| Provider Information | |||||||||
| NPI: | 1073546289 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTERMOUNTAIN AMBULATORY ANESTHESIA PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3661 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981243661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004756236 | ||||||||
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| Practice Location | |||||||||
| Address1: | 875 S VANGUARD WAY | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836428540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083735000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 02/23/2022 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | KIRK | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 2089600870 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 02/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 806036500 | 05 | ID | MEDICAID |