Basic Information
| Provider Information | |||||||||
| NPI: | 1013956705 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SWANSON | ||||||||
| FirstName: | JOEL | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3340 E GOLDSTONE WAY | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836421026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083026000 | ||||||||
| FaxNumber: | 2083026055 | ||||||||
| Practice Location | |||||||||
| Address1: | 323 E RIVERSIDE DR, SUITE 224 | ||||||||
| Address2: | SAMG EHP FAMILY MEDICINE | ||||||||
| City: | EAGLE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836166815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083026000 | ||||||||
| FaxNumber: | 2083026055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 11/15/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | M8006 | ID | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 805814100 | 05 | ID | MEDICAID |