1336223379 NPI number — PREMIER EMERGENCY PHYSICIANS OF IDAHO MEDICAL GROUP

Table of content: (NPI 1336223379)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336223379 NPI number — PREMIER EMERGENCY PHYSICIANS OF IDAHO MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIER EMERGENCY PHYSICIANS OF IDAHO MEDICAL GROUP
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:
1336223379
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/24/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8120
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19101-8120
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-444-7009
Provider Business Mailing Address Fax Number:
800-305-3233

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3 JACOBS GULCH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KELLOGG
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83837-2023
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-784-1221
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GATEWOOD
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
H.
Authorized Official Title or Position:
PRESIDENT PREMIER EMERENCY PHYSICIA
Authorized Official Telephone Number:
800-444-7009

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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