Basic Information
| Provider Information | |||||||||
| NPI: | 1780620633 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CALDWELL RADIOLOGICAL ASSOCIATES PROFESSIONAL ASSOCIATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9649 | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837074649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074728108 | ||||||||
| FaxNumber: | 2083441926 | ||||||||
| Practice Location | |||||||||
| Address1: | 1717 ARLINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | CALDWELL | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836054802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084553730 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 02/12/2009 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | LORELI | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2084553730 | ||||||||
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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 | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 002396000 | 05 | ID | MEDICAID |