Basic Information
| Provider Information | |||||||||
| NPI: | 1073697884 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UPPER VALLEY FAMILY MEDICINE PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UPPER VALLEY FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 711 RIGBY LAKE DR STE 115 | ||||||||
| Address2: | |||||||||
| City: | RIGBY | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834425230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087455021 | ||||||||
| FaxNumber: | 2087455026 | ||||||||
| Practice Location | |||||||||
| Address1: | 711 RIGBY LAKE DR STE 115 | ||||||||
| Address2: | |||||||||
| City: | RIGBY | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834425230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087455021 | ||||||||
| FaxNumber: | 2087455026 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | BERRETT | ||||||||
| AuthorizedOfficialFirstName: | DARIN | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2087455021 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8067451700 | 05 | ID | MEDICAID | 806913600 | 05 | ID | MEDICAID |