Basic Information
| Provider Information | |||||||||
| NPI: | 1821299553 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLUE LAKES GASTROENTEROLOGY PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 775 POLE LINE RD W | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833015814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088148300 | ||||||||
| FaxNumber: | 2087338970 | ||||||||
| Practice Location | |||||||||
| Address1: | 775 POLE LINE RD W | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833015814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088148300 | ||||||||
| FaxNumber: | 2087338970 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2007 | ||||||||
| LastUpdateDate: | 03/09/2013 | ||||||||
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| AuthorizedOfficialLastName: | WARD | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 2088148300 | ||||||||
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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 | 363L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 807132400 | 05 | ID | MEDICAID |