Basic Information
| Provider Information | |||||||||
| NPI: | 1184657389 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TREASURE VALLEY CARDIOLOGY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9589 | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837074589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084728117 | ||||||||
| FaxNumber: | 2084728172 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 N LIBERTY ST | ||||||||
| Address2: | SUITE 302 | ||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837048704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083221686 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 11/17/2014 | ||||||||
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| AuthorizedOfficialLastName: | WETHERLEY | ||||||||
| AuthorizedOfficialFirstName: | GRAHAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2083221686 | ||||||||
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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 | 363L00000X | NP642A | ID | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207RC0000X | M5449 | ID | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 002180300 | 05 | ID | MEDICAID | 807805900 | 05 | ID | MEDICAID |