Mountain Medical Physician Specialists of Idaho PC

Primary specialty

Diagnostic Radiology PhysicianTaxonomy code 2085R0202X

License

C176456 Issued in ID

Legal business name

MOUNTAIN MEDICAL PHYSICIAN SPECIALISTS OF IDAHO PC

Practice address

1501 Hiland Ave
Burley, ID 83318-2682

Phone

(801) 284-1755

Fax

(801) 262-3897

NPI assigned

Jan 17, 2008

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Clark A Davis

Title

Ceo

Phone

(801) 284-1705

Specialties & licenses 1

Addresses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1200528000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1226448000000",
    "number": "1053597237",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5444 GREEN ST",
            "city": "MURRAY",
            "state": "UT",
            "postal_code": "841235632",
            "telephone_number": "801-284-1755",
            "fax_number": "801-262-3897"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1501 HILAND AVE",
            "city": "BURLEY",
            "state": "ID",
            "postal_code": "833182682",
            "telephone_number": "801-284-1755",
            "fax_number": "801-262-3897"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MOUNTAIN MEDICAL PHYSICIAN SPECIALISTS OF IDAHO PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-01-17",
        "last_updated": "2008-11-12",
        "status": "A",
        "authorized_official_last_name": "DAVIS",
        "authorized_official_first_name": "CLARK",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "801-284-1705"
    },
    "taxonomies": [
        {
            "code": "2085R0202X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Radiology, Diagnostic Radiology",
            "state": "ID",
            "license": "C176456",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• All providers in Burley, ID
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• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 12, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.