Basic Information
| Provider Information | |||||||||
| NPI: | 1821208554 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MACNEIL | ||||||||
| FirstName: | JUSTINE | ||||||||
| MiddleName: | MARION | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 777 HOSPITAL WAY | ||||||||
| Address2: | DEPARTMENT OF EMERGENCY MEDICINE | ||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832015175 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082391801 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 777 HOSPITAL WAY | ||||||||
| Address2: | DEPARTMENT OF EMERGENCY MEDICINE | ||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832015175 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082391801 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2007 | ||||||||
| LastUpdateDate: | 11/18/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | M-10762 | ID | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.