1093101438 NPI number — MERIDIAN FAMILY MEDICINE

Table of content: (NPI 1093101438)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093101438 NPI number — MERIDIAN FAMILY MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MERIDIAN FAMILY MEDICINE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093101438
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
ISU RIDGE CRST
Provider Second Line Business Mailing Address:
APT L2
Provider Business Mailing Address City Name:
POCATELLO
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83209-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-530-1087
Provider Business Mailing Address Fax Number:
888-415-9555

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
444 HOSPITAL WAY
Provider Second Line Business Practice Location Address:
ROOM 219
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83209-2745
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-530-1087
Provider Business Practice Location Address Fax Number:
888-415-9555
Provider Enumeration Date:
04/13/2015

Additional Information

Authorized Official

Authorized Official Last Name:
DUNN
Authorized Official First Name:
NATALIA
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
208-530-1087

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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