Basic Information
| Provider Information | |||||||||
| NPI: | 1942782735 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IDAHO SLEEP SPECIALISTS PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | IDAHO SLEEP SPECIALISTS SLEEP LAB | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9589 | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837074589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084728107 | ||||||||
| FaxNumber: | 2084728172 | ||||||||
| Practice Location | |||||||||
| Address1: | 403 S 11TH ST STE 210 | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837026968 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088950411 | ||||||||
| FaxNumber: | 2088950406 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2018 | ||||||||
| LastUpdateDate: | 08/29/2018 | ||||||||
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| AuthorizedOfficialLastName: | TROYER | ||||||||
| AuthorizedOfficialFirstName: | BRETT | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2088950411 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS1200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Sleep Disorder Diagnostic |
ID Information
| ID | Type | State | Issuer | Description | 8N847 | 01 | ID | BLUE CROSS OF IDAHO | OTHER |