Basic Information
| Provider Information | |||||||||
| NPI: | 1205850823 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOUNTAIN STATES NEONATOLOGY, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1301 CONCORD TER | ||||||||
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| City: | SUNRISE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333232843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002433839 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1055 N CURTIS RD | ||||||||
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| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837061309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083677610 | ||||||||
| FaxNumber: | 2083677616 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 07/09/2021 | ||||||||
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| AuthorizedOfficialLastName: | SANDERS | ||||||||
| AuthorizedOfficialFirstName: | NANETTE | ||||||||
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| AuthorizedOfficialTitleorPosition: | RCM DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8002433839 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VM0101X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine | 2080P0203X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine | 363LN0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal | 2080N0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 806075900 | 05 | ID | MEDICAID |