1780820076 NPI number — ALLIANCE MEDICAL GROUP, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780820076 NPI number — ALLIANCE MEDICAL GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALLIANCE MEDICAL GROUP, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PRIMARY HEALTH MEDICAL GROUP
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780820076
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/13/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 191050
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83719-1050
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-955-6500
Provider Business Mailing Address Fax Number:
208-955-6503

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3280 E. LANARK DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-895-8670
Provider Business Practice Location Address Fax Number:
208-955-0494
Provider Enumeration Date:
12/17/2008

Additional Information

Authorized Official

Authorized Official Last Name:
PETERMAN
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
208-955-6506

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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