Basic Information
| Provider Information | |||||||||
| NPI: | 1992797088 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SALEM | ||||||||
| FirstName: | ALLEN | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2442 E. 25TH ST. | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834040000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085524909 | ||||||||
| FaxNumber: | 9406123636 | ||||||||
| Practice Location | |||||||||
| Address1: | 2442 E. 25TH ST. | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834040000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085524909 | ||||||||
| FaxNumber: | 9406123636 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2005 | ||||||||
| LastUpdateDate: | 11/22/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | K9165 | TX | N | Other Service Providers | Specialist | 207RP1001X | K9165 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RS0012X | K9165 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0033HG | 01 | TX | BCBS | OTHER | 0033HGT | 01 | TX | BCBS | OTHER | 042379003 | 05 | TX | MEDICAID |