Provider Demographics
NPI:1013204445
Name:MACHEN FAMILY MEDICINE, PC
Entity Type:Organization
Organization Name:MACHEN FAMILY MEDICINE, PC
Other - Org Name:SHANE G MACHEN, DO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:G
Authorized Official - Last Name:MACHEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:208-522-7666
Mailing Address - Street 1:1995 E 17TH ST STE A
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6493
Mailing Address - Country:US
Mailing Address - Phone:208-522-7666
Mailing Address - Fax:208-524-2821
Practice Address - Street 1:1995 E 17TH ST STE A
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6493
Practice Address - Country:US
Practice Address - Phone:208-522-7666
Practice Address - Fax:208-524-2821
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MACHEN FAMILY MEDICINE, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-07-06
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-0611207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1196447Medicare PIN