NPIMap

Organization Active NPI

Intermountain Medical Imaging LLC

  • Diagnostic Radiology Physician
  • Boise, ID
National Provider Identifier
1669423679
Registry record updated Oct 31, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Diagnostic Radiology PhysicianTaxonomy code 2085R0202X
Legal business name
INTERMOUNTAIN MEDICAL IMAGING LLC
Practice address
927 W Myrtle St
Boise, ID 83702-7061
Phone
(208) 367-7510
Fax
(208) 367-6367
NPI assigned
May 15, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 31, 2023

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

Authorized official

Name
Mr. Wayne Baldwin
Title
Executive Director
Phone
(208) 384-9060

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Diagnostic Radiology PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 2085R0202X Primary

Addresses

Primary practice location

927 W Myrtle St
Boise, ID 83702-7061

Mailing address

877 W Main St Ste 603
Boise, ID 83702-6070
Phone (208) 954-8175

Other identifiers 1

IdentifierTypeStateIssuer
806456500MedicaidID

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ID, OR, VA, GA4 enrollments

Enrollment records 4

Enrollment IDStateProvider typePAC IDDetails
O20090130000423 ID Part B Supplier - Clinic/Group Practice 7517870918 Receives reassigned benefits from 39 practitioners
5 other NPIs on this enrollment
Practice locations: Meridian, ID; Sun Valley, ID; Ketchum, ID; Eagle, ID; Boise, ID
O20140210001568 OR Part B Supplier - Clinic/Group Practice 7517870918 Receives reassigned benefits from 1 practitioner
4 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Portland, OR
O20230605002415 VA Part B Supplier - Clinic/Group Practice 7517870918 Receives reassigned benefits from 1 practitioner
3 other NPIs on this enrollment
Practice locations: Charlottesville, VA
O20250131000764 GA Part B Supplier - Clinic/Group Practice 7517870918 Receives reassigned benefits from 2 practitioners
3 other NPIs on this enrollment
Practice locations: Johns Creek, GA; Buford, GA

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 3

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

Locations

323 E Riverside Dr
Ste 100
Eagle, ID 83616

240 E Hidalgo Ave
Raymondville, TX 78580
Phone (956) 689-5977

Practitioners & affiliated clinicians

Practitioners 41

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 41

NPI Registry JSON

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

{
    "created_epoch": "1147651200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1698710400000",
    "number": "1669423679",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "877 W MAIN ST STE 603",
            "city": "BOISE",
            "state": "ID",
            "postal_code": "837026070",
            "telephone_number": "208-954-8175",
            "fax_number": "208-384-9023"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "927 W MYRTLE ST",
            "city": "BOISE",
            "state": "ID",
            "postal_code": "837027061",
            "telephone_number": "208-367-7510",
            "fax_number": "208-367-6367"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "INTERMOUNTAIN MEDICAL IMAGING LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-15",
        "last_updated": "2023-10-31",
        "certification_date": "2023-10-31",
        "status": "A",
        "authorized_official_last_name": "BALDWIN",
        "authorized_official_first_name": "WAYNE",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "208-384-9060",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "2085R0202X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Radiology, Diagnostic Radiology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "806456500",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Boise, ID

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 31, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.