Provider Demographics
NPI:1073601233
Name:PHYSICIANS CLINIC PLLC
Entity Type:Organization
Organization Name:PHYSICIANS CLINIC PLLC
Other - Org Name:MCMILLAN MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CORINNE
Authorized Official - Middle Name:K
Authorized Official - Last Name:CHASTAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-375-0500
Mailing Address - Street 1:4750 N FIVE MILE RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-2715
Mailing Address - Country:US
Mailing Address - Phone:208-375-0500
Mailing Address - Fax:208-375-4310
Practice Address - Street 1:4750 N FIVE MILE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-2715
Practice Address - Country:US
Practice Address - Phone:208-375-0500
Practice Address - Fax:208-375-4310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8D319OtherBLUE CROSS
ID8D319OtherBLUE CROSS