Basic Information
| Provider Information | |||||||||
| NPI: | 1780032326 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IDAHO STATE UNIVERSITY DEPARTMENT OF FAMILY MEDICINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 N 8TH AVE | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832015757 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082326260 | ||||||||
| FaxNumber: | 2082326259 | ||||||||
| Practice Location | |||||||||
| Address1: | 465 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832014008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082824141 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2016 | ||||||||
| LastUpdateDate: | 05/24/2016 | ||||||||
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| AuthorizedOfficialLastName: | POWELL | ||||||||
| AuthorizedOfficialFirstName: | LAURIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | AUTHORIZATION SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 2082326260 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HEALTH WEST INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.