Basic Information
| Provider Information | |||||||||
| NPI: | 1700053774 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST BENEDICTS FMC PHYSICIAN ASSISTANTS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 709 N LINCOLN AVE | ||||||||
| Address2: | |||||||||
| City: | JEROME | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833381851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083244301 | ||||||||
| FaxNumber: | 2083249529 | ||||||||
| Practice Location | |||||||||
| Address1: | 709 N LINCOLN AVE | ||||||||
| Address2: | |||||||||
| City: | JEROME | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833381851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083244301 | ||||||||
| FaxNumber: | 2083249529 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2008 | ||||||||
| LastUpdateDate: | 05/09/2008 | ||||||||
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| AuthorizedOfficialLastName: | STEVENSON | ||||||||
| AuthorizedOfficialFirstName: | ALAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2083241122 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST BENEDICTS FAMILY MEDICAL CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 08 | ID | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.