Basic Information
| Provider Information | |||||||||
| NPI: | 1467963496 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KURT E KRACAW MD LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3208 | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834033208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085234906 | ||||||||
| FaxNumber: | 2085232025 | ||||||||
| Practice Location | |||||||||
| Address1: | 426 FARNSWORTH WAY STE 1 | ||||||||
| Address2: | |||||||||
| City: | RIGBY | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834424713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087459411 | ||||||||
| FaxNumber: | 2087459910 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2017 | ||||||||
| LastUpdateDate: | 04/03/2018 | ||||||||
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| AuthorizedOfficialLastName: | KRACAW | ||||||||
| AuthorizedOfficialFirstName: | KURT | ||||||||
| AuthorizedOfficialMiddleName: | EDWIN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7757724208 | ||||||||
| 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 | 207Q00000X | M-13115 | ID | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1285723460 | 01 | TYPE 1 NPI | OTHER |