Provider Demographics
NPI:1093965212
Name:TOTAL FAMILY MEDICINE PLLC
Entity Type:Organization
Organization Name:TOTAL FAMILY MEDICINE PLLC
Other - Org Name:TERESA KAY JOHNSON MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-529-2544
Mailing Address - Street 1:1995 E 17TH ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6493
Mailing Address - Country:US
Mailing Address - Phone:208-529-2544
Mailing Address - Fax:208-529-3771
Practice Address - Street 1:1995 E 17TH ST
Practice Address - Street 2:SUITE 5
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6493
Practice Address - Country:US
Practice Address - Phone:208-529-2544
Practice Address - Fax:208-529-3771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-24
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM8742174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806599100Medicaid
ID806599100Medicaid
IDG90119Medicare UPIN