Basic Information
| Provider Information | |||||||||
| NPI: | 1649300138 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLACK CANYON FAMILY MEDICINE PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 16820 | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837156820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083239130 | ||||||||
| FaxNumber: | 2083239070 | ||||||||
| Practice Location | |||||||||
| Address1: | 119 N WARDWELL AVE | ||||||||
| Address2: | |||||||||
| City: | EMMETT | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836173040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083656311 | ||||||||
| FaxNumber: | 2083651003 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MCGUFFEY | ||||||||
| AuthorizedOfficialFirstName: | TINA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2083656311 | ||||||||
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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 | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.