Basic Information
| Provider Information | |||||||||
| NPI: | 1215973169 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IDAHO RADIOLOGY ASSOCIATES PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9649 | ||||||||
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| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837074649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084728119 | ||||||||
| FaxNumber: | 2083441926 | ||||||||
| Practice Location | |||||||||
| Address1: | 2035 SILVERCREEK LN | ||||||||
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| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837066112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083680095 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 07/28/2007 | ||||||||
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| AuthorizedOfficialLastName: | NEWTON | ||||||||
| AuthorizedOfficialFirstName: | DIANE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2083680095 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0700X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.