Basic Information
| Provider Information | |||||||||
| NPI: | 1790856797 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAUMGARDNER | ||||||||
| FirstName: | JUDY | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MS PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1612 | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834031612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085252090 | ||||||||
| FaxNumber: | 2085252662 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 SKI HILL | ||||||||
| Address2: | |||||||||
| City: | DRIGGS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083543128 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2006 | ||||||||
| LastUpdateDate: | 06/04/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT-350 | ID | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 807140300 | 05 | ID | MEDICAID |