Basic Information
| Provider Information | |||||||||
| NPI: | 1366560971 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IDAHO FALLS PEDIATRICS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2375 CORONADO ST | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834047407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085224600 | ||||||||
| FaxNumber: | 2085527521 | ||||||||
| Practice Location | |||||||||
| Address1: | 2375 CORONADO ST | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834047407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085224600 | ||||||||
| FaxNumber: | 2085527521 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | PORTER | ||||||||
| AuthorizedOfficialFirstName: | RON | ||||||||
| AuthorizedOfficialMiddleName: | WADE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2085224600 | ||||||||
| IsSoleProprietor: | |||||||||
| 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 | 2080A0000X | M7271 | ID | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
No ID Information.