Basic Information
| Provider Information | |||||||||
| NPI: | 1407124753 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IDAHO FALLS PULMONARY SLEEP & CRITICAL CARE SPECIALISTS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2442 E 25TH ST | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834047549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085524909 | ||||||||
| FaxNumber: | 2085226101 | ||||||||
| Practice Location | |||||||||
| Address1: | 2442 E 25TH ST | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834047549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085524909 | ||||||||
| FaxNumber: | 2085226101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2011 | ||||||||
| LastUpdateDate: | 01/04/2012 | ||||||||
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| AuthorizedOfficialLastName: | SALEM | ||||||||
| AuthorizedOfficialFirstName: | ALLEN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2085524909 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RS0012X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | 207RC0200X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8P562 | 01 | ID | BLUE CROSS OF IDAHO | OTHER |