Basic Information
| Provider Information | |||||||||
| NPI: | 1508807926 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSICIAN CENTER , A PROFESSIONAL COMPANY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 775 POLE LINE RD W | ||||||||
| Address2: | SUITES 105 & 111 | ||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833015814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088148000 | ||||||||
| FaxNumber: | 2087339402 | ||||||||
| Practice Location | |||||||||
| Address1: | 775 POLE LINE RD W | ||||||||
| Address2: | SUITES 105 & 111 | ||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833015814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088148000 | ||||||||
| FaxNumber: | 2087339402 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 03/09/2013 | ||||||||
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| AuthorizedOfficialLastName: | MOFFITT | ||||||||
| AuthorizedOfficialFirstName: | MITCHELL | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 2088148000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 2083X0100X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Preventive Medicine | Occupational Medicine | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | CD3787 | 01 | ID | RR MEDICARE | OTHER | 002746900 | 05 | ID | MEDICAID |