Basic Information
| Provider Information | |||||||||
| NPI: | 1154976983 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IDAHO EAR CLINIC LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1209 N SUMMERBROOK AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836428750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2089385823 | ||||||||
| FaxNumber: | 2089385306 | ||||||||
| Practice Location | |||||||||
| Address1: | 1209 N SUMMERBROOK AVE | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836428749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2089385823 | ||||||||
| FaxNumber: | 2089385306 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2019 | ||||||||
| LastUpdateDate: | 05/19/2022 | ||||||||
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| AuthorizedOfficialLastName: | CRAWFORD | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | V | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2089385823 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 05/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207YX0901X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | Otology & Neurotology |
No ID Information.