Basic Information
| Provider Information | |||||||||
| NPI: | 1063466225 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BOISE PATHOLOGY GROUP P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9589 | ||||||||
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| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837074589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084728104 | ||||||||
| FaxNumber: | 2083441926 | ||||||||
| Practice Location | |||||||||
| Address1: | 190 E BANNOCK ST | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837126241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083812367 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | STILLINGER | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | SECRETARY-TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 2083812367 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZC0500X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZH0000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Hematology | 207ZP0102X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZD0900X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Dermatopathology |
No ID Information.