Basic Information
| Provider Information | |||||||||
| NPI: | 1124355813 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHS MD #1, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PORTNEUF MEDICAL PRACTICES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4168 | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832054168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082392110 | ||||||||
| FaxNumber: | 2082392145 | ||||||||
| Practice Location | |||||||||
| Address1: | 651 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832014071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082392110 | ||||||||
| FaxNumber: | 2082392145 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2009 | ||||||||
| LastUpdateDate: | 03/02/2010 | ||||||||
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| AuthorizedOfficialLastName: | ABREU | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2082392110 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | POCATELLO HEALTH SERVICES, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | ID | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.