Basic Information
Provider Information | |||||||||
NPI: | 1780867457 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOUTHEAST IDAHO GASTROENTEROLOGY, PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1151 HOSPITAL WAY STE A | ||||||||
Address2: |   | ||||||||
City: | POCATELLO | ||||||||
State: | ID | ||||||||
PostalCode: | 832015091 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2082326616 | ||||||||
FaxNumber: | 2082326618 | ||||||||
Practice Location | |||||||||
Address1: | 1151 HOSPITAL WAY STE A | ||||||||
Address2: |   | ||||||||
City: | POCATELLO | ||||||||
State: | ID | ||||||||
PostalCode: | 832015091 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2082326616 | ||||||||
FaxNumber: | 2082326618 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/17/2007 | ||||||||
LastUpdateDate: | 12/17/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FERREL | ||||||||
AuthorizedOfficialFirstName: | DEBBIE | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
AuthorizedOfficialTelephone: | 2082326616 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA-629 | ID | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
ID | Type | State | Issuer | Description | 806196200 | 05 | ID |   | MEDICAID |