Basic Information
| Provider Information | |||||||||
| NPI: | 1730447186 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PARKER | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2265 E SUNNYSIDE RD | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834047598 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085425000 | ||||||||
| FaxNumber: | 2085425151 | ||||||||
| Practice Location | |||||||||
| Address1: | 3100 CHANNING WAY | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085296111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2012 | ||||||||
| LastUpdateDate: | 05/14/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 8809928-1205 | UT | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | M-13992 | ID | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1730447186 | 05 | ID | MEDICAID |