Provider Demographics
NPI:1134139991
Name:BAILLIE, JON-ERIC (MD)
Entity Type:Individual
Prefix:DR
First Name:JON-ERIC
Middle Name:
Last Name:BAILLIE
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 1:8100 W EMERALD ST STE 180
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9069
Mailing Address - Country:US
Mailing Address - Phone:208-377-3299
Mailing Address - Fax:208-460-5227
Practice Address - Street 1:8100 W EMERALD ST STE 180
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704
Practice Address - Country:US
Practice Address - Phone:208-377-3299
Practice Address - Fax:208-460-5227
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7882207Q00000X, 207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805693500Medicaid
ID1143766Medicare ID - Type Unspecified
ID805693500Medicaid