Basic Information
| Provider Information | |||||||||
| NPI: | 1598731010 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STEPHENS | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2265 E SUNNYSIDE RD | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834047598 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085425000 | ||||||||
| FaxNumber: | 2085425151 | ||||||||
| Practice Location | |||||||||
| Address1: | 777 HOSPITAL WAY | ||||||||
| Address2: | BLDG B | ||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832017533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082391000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2006 | ||||||||
| LastUpdateDate: | 09/26/2017 | ||||||||
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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 | 2085R0202X | M5294 | ID | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 003945600 | 05 | ID | MEDICAID |