Basic Information
| Provider Information | |||||||||
| NPI: | 1528704863 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTEGRATED DERMATOLOGY OF BOISE, LLC | ||||||||
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| Address1: | 4700 EXCHANGE CT STE 110 | ||||||||
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| City: | BOCA RATON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334314450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5613142000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3277 E LOUISE DR STE 360 | ||||||||
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| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836429359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5613142000 | ||||||||
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| ProviderEnumerationDate: | 05/10/2022 | ||||||||
| LastUpdateDate: | 05/10/2022 | ||||||||
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| AuthorizedOfficialLastName: | LUCHETTI | ||||||||
| AuthorizedOfficialFirstName: | MARY ELLEN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED GROUP OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 5613142000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 05/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.