Basic Information
| Provider Information | |||||||||
| NPI: | 1932552379 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CRAIG J DENNY MD PROF | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3354 | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834033354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085252090 | ||||||||
| FaxNumber: | 2085238978 | ||||||||
| Practice Location | |||||||||
| Address1: | 2280 E 25TH ST | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834047542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082272100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2016 | ||||||||
| LastUpdateDate: | 09/28/2016 | ||||||||
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| AuthorizedOfficialLastName: | POPEJOY | ||||||||
| AuthorizedOfficialFirstName: | JULI | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2085252090 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | M-9188 | ID | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 1720071319 | 05 | ID | MEDICAID |