Basic Information
| Provider Information | |||||||||
| NPI: | 1497795215 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REA | ||||||||
| FirstName: | TED | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1411 FALLS AVE E | ||||||||
| Address2: | STE 1151 | ||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833013455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087323030 | ||||||||
| FaxNumber: | 2087338970 | ||||||||
| Practice Location | |||||||||
| Address1: | 1411 FALLS AVE E | ||||||||
| Address2: | STE 1151 | ||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833013455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2089334277 | ||||||||
| FaxNumber: | 2089334280 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 12/27/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | M6676 | ID | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 002769900 | 05 | ID | MEDICAID | RR MEDICARE | 01 | ID | 100016984 | OTHER |