Basic Information
| Provider Information | |||||||||
| NPI: | 1376531004 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SWENSON | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | SCOTT | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1308 8TH ST STE 1 | ||||||||
| Address2: | |||||||||
| City: | RUPERT | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833501535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084364322 | ||||||||
| FaxNumber: | 2084361312 | ||||||||
| Practice Location | |||||||||
| Address1: | 1308 8TH ST STE 1 | ||||||||
| Address2: | |||||||||
| City: | RUPERT | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084364322 | ||||||||
| FaxNumber: | 2084361312 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2005 | ||||||||
| LastUpdateDate: | 06/06/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | MR0835 | ID | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | M9766 | ID | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | M8073867 | 05 | ID | MEDICAID | 78193 | 01 | ID | BLX | OTHER | M0027582 | 05 | ID | MEDICAID |