Provider Demographics
NPI:1013008697
Name:RAMMELL, COREY T (MD)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:T
Last Name:RAMMELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:393 E 2ND N
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-1605
Mailing Address - Country:US
Mailing Address - Phone:208-356-5401
Mailing Address - Fax:
Practice Address - Street 1:393 E 2ND N
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-1605
Practice Address - Country:US
Practice Address - Phone:208-356-3691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6388207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDM6388OtherSTATE LICENSE #
ID003900500Medicaid
ID000010000817OtherBLUE SHIELD OF IDAHO ID#
ID1129411Medicare ID - Type UnspecifiedCIGNA MEDICARE #