Provider Demographics
NPI:1164476131
Name:REDWINE, KAREN M (MD)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:M
Last Name:REDWINE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 E JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6273
Mailing Address - Country:US
Mailing Address - Phone:208-381-7336
Mailing Address - Fax:
Practice Address - Street 1:305 E JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6273
Practice Address - Country:US
Practice Address - Phone:208-381-7336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM0173208000000X, 2080P0210X
ARE-51762080P0210X
IDM-132002080P0210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric Nephrology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR164436001Medicaid
TX180864401Medicaid
TX8P2608OtherBCBSTX
TX180864402OtherCSHCN
TX180864402OtherCSHCN
I54285Medicare UPIN
AR5N842Medicare PIN