Provider Demographics
NPI:1003157801
Name:IDAHO REGIONAL HAND & UPPER EXTREMITY CENTER PLLC
Entity Type:Organization
Organization Name:IDAHO REGIONAL HAND & UPPER EXTREMITY CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:DEE
Authorized Official - Last Name:STUCKI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:208-235-4263
Mailing Address - Street 1:444 HOSPITAL WAY STE 710
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2745
Mailing Address - Country:US
Mailing Address - Phone:208-235-4263
Mailing Address - Fax:208-233-4268
Practice Address - Street 1:444 HOSPITAL WAY STE 710
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201
Practice Address - Country:US
Practice Address - Phone:208-235-4263
Practice Address - Fax:208-233-4268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-05
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-0574207XS0106X
IDM-8547207XS0106X
IDPA-684363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand SurgeryGroup - Single Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty