Basic Information
| Provider Information | |||||||||
| NPI: | 1275829376 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VAN DE GRIEND | ||||||||
| FirstName: | PHILIP | ||||||||
| MiddleName: | JON | ||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 465 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832014008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082344700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 465 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832014008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082327862 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2011 | ||||||||
| LastUpdateDate: | 09/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD-42445 | IA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | LL33736 | SC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 2014-01351 | NC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | M-15982 | ID | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | NC2135 | 05 | SC | MEDICAID | 1275829376 | 05 | NC | MEDICAID |