Basic Information
| Provider Information | |||||||||
| NPI: | 1801292115 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IDAHO STATE UNIVERSITY | ||||||||
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| OtherOrganizationName: | IDAHO STATE SPORTS MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5050 SPRING VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752443995 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8005559073 | ||||||||
| FaxNumber: | 9723673452 | ||||||||
| Practice Location | |||||||||
| Address1: | 921 S 8TH AVE STOP 8173 | ||||||||
| Address2: | SPORTS AND ORTHOPAEDIC CENTER | ||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832098173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082823408 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2014 | ||||||||
| LastUpdateDate: | 11/13/2014 | ||||||||
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| AuthorizedOfficialLastName: | WOTOWEY | ||||||||
| AuthorizedOfficialFirstName: | JODI | ||||||||
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| AuthorizedOfficialTitleorPosition: | HEAD ATHLETIC TRAINER | ||||||||
| AuthorizedOfficialTelephone: | 2082823408 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207X00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0005X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207Q00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.