Basic Information
| Provider Information | |||||||||
| NPI: | 1730272006 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOUNTAIN STATES MEDICAL GROUP PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4236 | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837114236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083782840 | ||||||||
| FaxNumber: | 2083239070 | ||||||||
| Practice Location | |||||||||
| Address1: | 4809 FAIRVIEW AVENUE | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837062242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083782840 | ||||||||
| FaxNumber: | 2083239070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2006 | ||||||||
| LastUpdateDate: | 09/15/2008 | ||||||||
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| AuthorizedOfficialLastName: | MCCHRYSTAL | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2083782840 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PA | ||||||||
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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 |
ID Information
| ID | Type | State | Issuer | Description | 000010017966 | 01 | ID | RBSI | OTHER | 8C196 | 01 | ID | BLUE CROSS | OTHER |