Basic Information
Provider Information | |||||||||
NPI: | 1245414028 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PHYSICIAN CENTER A PROFESSIONAL COMPANY MID LEVEL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 775 POLE LINE RD W | ||||||||
Address2: | SUITE 105 & 111 | ||||||||
City: | TWIN FALLS | ||||||||
State: | ID | ||||||||
PostalCode: | 833015814 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2088148000 | ||||||||
FaxNumber: | 2087339402 | ||||||||
Practice Location | |||||||||
Address1: | 775 POLE LINE RD W | ||||||||
Address2: | SUITE 105 & 111 | ||||||||
City: | TWIN FALLS | ||||||||
State: | ID | ||||||||
PostalCode: | 833015814 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2088148000 | ||||||||
FaxNumber: | 2087339402 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/28/2007 | ||||||||
LastUpdateDate: | 03/09/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MOFFITT | ||||||||
AuthorizedOfficialFirstName: | MITCHELL | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
AuthorizedOfficialTelephone: | 2088148000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   | 207Q00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 8050368 | 05 | ID |   | MEDICAID |