Basic Information
| Provider Information | |||||||||
| NPI: | 1336223379 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PREMIER EMERGENCY PHYSICIANS OF IDAHO MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8120 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191018120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004447009 | ||||||||
| FaxNumber: | 8003053233 | ||||||||
| Practice Location | |||||||||
| Address1: | 3 JACOBS GULCH RD | ||||||||
| Address2: | |||||||||
| City: | KELLOGG | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838372023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087841221 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 03/24/2008 | ||||||||
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| AuthorizedOfficialLastName: | GATEWOOD | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | H. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT PREMIER EMERENCY PHYSICIA | ||||||||
| AuthorizedOfficialTelephone: | 8004447009 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.