Basic Information
| Provider Information | |||||||||
| NPI: | 1598789950 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IDAHO NEPHROLOGY ASSOCIATES, L.L.C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5610 GAGE ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837061349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083673370 | ||||||||
| FaxNumber: | 2083673003 | ||||||||
| Practice Location | |||||||||
| Address1: | 5610 GAGE ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837061349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083673370 | ||||||||
| FaxNumber: | 2083673003 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 01/08/2008 | ||||||||
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| AuthorizedOfficialLastName: | ADCOX | ||||||||
| AuthorizedOfficialFirstName: | MICHEAL | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 2083673370 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | CD6921 | 01 | ID | RR MEDICARE | OTHER | 000010006436 | 01 | ID | BLUE SHIELD OF IDAHO | OTHER | 8A133 | 01 | ID | BLUE CROSS OF IDAHO | OTHER |