Basic Information
| Provider Information | |||||||||
| NPI: | 1609940501 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CATALYST MEDICAL GROUP, PLLC | ||||||||
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| OtherOrganizationName: | MOSCOW FAMILY MEDICINE, PA | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 623 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MOSCOW | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838432983 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088822011 | ||||||||
| FaxNumber: | 2088831853 | ||||||||
| Practice Location | |||||||||
| Address1: | 623 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MOSCOW | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838432983 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088822011 | ||||||||
| FaxNumber: | 2088831853 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 11/29/2016 | ||||||||
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| AuthorizedOfficialLastName: | GEIER | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2088822011 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 002399300 | 05 | ID | MEDICAID | 805220900 | 05 | ID | MEDICAID |