Basic Information
| Provider Information | |||||||||
| NPI: | 1699942854 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OASIS MEDICAL CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3217 W BAVARIA ST | ||||||||
| Address2: | |||||||||
| City: | EAGLE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082866676 | ||||||||
| FaxNumber: | 2086728385 | ||||||||
| Practice Location | |||||||||
| Address1: | 9000 W DUCK LAKE DR | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837141834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082866676 | ||||||||
| FaxNumber: | 2086728385 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2008 | ||||||||
| LastUpdateDate: | 05/15/2008 | ||||||||
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| AuthorizedOfficialLastName: | MCMULLIN | ||||||||
| AuthorizedOfficialFirstName: | JESSE | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2082866676 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | RT, DS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QX0100X | N | Ambulatory Health Care Facilities | Clinic/Center | Occupational Medicine | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.