Basic Information
| Provider Information | |||||||||
| NPI: | 1720244700 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JAMES G. SACCOMANDO, JR, M.D P.A. | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1423 W FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837025024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083452212 | ||||||||
| FaxNumber: | 2083452282 | ||||||||
| Practice Location | |||||||||
| Address1: | 1423 W FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837025024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083452212 | ||||||||
| FaxNumber: | 2083452282 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2008 | ||||||||
| LastUpdateDate: | 03/08/2018 | ||||||||
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| AuthorizedOfficialLastName: | SACCOMANDO | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 2083452212 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | M9565 | ID | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 807512200 | 05 | ID | MEDICAID |