Basic Information
| Provider Information | |||||||||
| NPI: | 1730133208 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IDAHO EMERGENCY PHYSICIANS, P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5666 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802175666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083221730 | ||||||||
| FaxNumber: | 2083221731 | ||||||||
| Practice Location | |||||||||
| Address1: | 2963 E COPPER POINT DR | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836429055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083221730 | ||||||||
| FaxNumber: | 2083221731 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 09/25/2015 | ||||||||
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| AuthorizedOfficialLastName: | WILIDING | ||||||||
| AuthorizedOfficialFirstName: | BRANDON | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHAIRMAN AND PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2083221730 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 002426500 | 05 | ID | MEDICAID |