Basic Information
| Provider Information | |||||||||
| NPI: | 1194042713 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BIRCH | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 190 E BANNOCK ST | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837126241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087068526 | ||||||||
| FaxNumber: | 2088147491 | ||||||||
| Practice Location | |||||||||
| Address1: | 755 POLE LINE ROAD WEST | ||||||||
| Address2: | SUITE 111 | ||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833010000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088148000 | ||||||||
| FaxNumber: | 2087339402 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2010 | ||||||||
| LastUpdateDate: | 02/10/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | M-12019 | ID | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.