# INTERMOUNTAIN MEDICAL GROUP, INC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1356397673
- **Authorized official:** JENNIFER L JACKSON (SENIOR DIRECTOR PROVIDER ENROLLMENT)
- **Authorized official phone:** (877) 892-9815

## Contact information

- **Practice address:** 610 WYOMING AVE, KINGSTON, PA 18704-3702
- **Practice address phone:** (570) 288-5441
- **Practice address fax:** (570) 288-5842
- **Mailing address:** 4000 MERIDIAN BLVD, FRANKLIN, TN 37067-6325
- **Mailing address phone:** (615) 465-7000
- **Mailing address fax:** (615) 628-6877

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 133V00000X | Registered Dietitian | — | NULL | — |
| 133V00000X | Registered Dietitian | — | — | — |
| 207Q00000X | Family Medicine Physician | — | NULL | Yes |
| 207Q00000X | Family Medicine Physician | — | — | Yes |
| 207R00000X | Internal Medicine Physician | — | NULL | — |
| 207R00000X | Internal Medicine Physician | — | — | — |
| 207V00000X | Obstetrics & Gynecology Physician | — | NULL | — |
| 207V00000X | Obstetrics & Gynecology Physician | — | — | — |
| 207X00000X | Orthopaedic Surgery Physician | — | NULL | — |
| 207X00000X | Orthopaedic Surgery Physician | — | — | — |
| 2084N0400X | Neurology Physician | — | NULL | — |
| 2084N0400X | Neurology Physician | — | — | — |
| 2085R0202X | Diagnostic Radiology Physician | — | NULL | — |
| 2085R0202X | Diagnostic Radiology Physician | — | — | — |
| 208600000X | Surgery Physician | — | NULL | — |
| 208600000X | Surgery Physician | — | — | — |
| 208800000X | Urology Physician | — | NULL | — |
| 208800000X | Urology Physician | — | — | — |
| 208D00000X | General Practice Physician | — | NULL | — |
| 208D00000X | General Practice Physician | — | — | — |
| 213ES0103X | Foot & Ankle Surgery Podiatrist | — | PA | — |
| 363AM0700X | Medical Physician Assistant | — | NULL | — |
| 363AM0700X | Medical Physician Assistant | — | — | — |
| 363L00000X | Nurse Practitioner | — | NULL | — |
| 363L00000X | Nurse Practitioner | — | — | — |

## Other

- **Enumeration date:** 05/26/2006
- **Last updated:** 01/25/2022

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 100755627 | — | PA |
| 01 | — | 1624037 | HIGHMARK BLUE SHIELD | PA |
| 01 | — | 510820 | HIGHMARK BLUE SHIELD | PW |