Organization
INTERMOUNTAIN MEDICAL GROUP, INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JENNIFER L JACKSON (SENIOR DIRECTOR PROVIDER ENROLLMENT)
(877) 892-9815
Entity
Organization
Contact information
Practice address
610 WYOMING AVE, KINGSTON, PA 18704-3702
(570) 288-5441
(570) 288-5842
Mailing address
4000 MERIDIAN BLVD, FRANKLIN, TN 37067-6325
(615) 465-7000
(615) 628-6877
Taxonomy
Speciality
Code
Description
License number
State
133V00000X
Registered Dietitian
—
—
207Q00000X
Family Medicine Physician
Primary
—
—
207R00000X
Internal Medicine Physician
—
—
207V00000X
Obstetrics & Gynecology Physician
—
—
207X00000X
Orthopaedic Surgery Physician
—
—
2084N0400X
Neurology Physician
—
—
2085R0202X
Diagnostic Radiology Physician
—
—
208600000X
Surgery Physician
—
—
208800000X
Urology Physician
—
—
208D00000X
General Practice Physician
—
—
213ES0103X
Foot & Ankle Surgery Podiatrist
—
PA
363AM0700X
Medical Physician Assistant
—
—
363L00000X
Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100755627
—
PA
01
—
1624037
HIGHMARK BLUE SHIELD
PA
01
—
510820
HIGHMARK BLUE SHIELD
PW
Enumeration date
05/26/2006
Last updated
01/25/2022
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