Basic Information
| Provider Information | |||||||||
| NPI: | 1558641274 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OASIS PEDIATRICS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3217 W BAVARIA ST | ||||||||
| Address2: | |||||||||
| City: | EAGLE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836165171 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086022863 | ||||||||
| FaxNumber: | 2089473419 | ||||||||
| Practice Location | |||||||||
| Address1: | 3217 W BAVARIA ST | ||||||||
| Address2: | |||||||||
| City: | EAGLE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836165171 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086022863 | ||||||||
| FaxNumber: | 2089473419 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2011 | ||||||||
| LastUpdateDate: | 08/25/2011 | ||||||||
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| AuthorizedOfficialLastName: | HUMPHREY | ||||||||
| AuthorizedOfficialFirstName: | CARRIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRINCIPAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2086022863 | ||||||||
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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 | 208000000X | M9582 | ID | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 80673100 | 05 | ID | MEDICAID |