Provider Demographics
NPI:1164531943
Name:OBSTETRICS AND GYNECOLOGY ASSOCIATES OF IDAHO FALLS
Entity Type:Organization
Organization Name:OBSTETRICS AND GYNECOLOGY ASSOCIATES OF IDAHO FALLS
Other - Org Name:OB-GYN ASSOC OF IDAHO FALLS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TESS
Authorized Official - Middle Name:
Authorized Official - Last Name:HIBBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-522-0747
Mailing Address - Street 1:2065 E 17TH ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8042
Mailing Address - Country:US
Mailing Address - Phone:208-522-0747
Mailing Address - Fax:208-522-9641
Practice Address - Street 1:2065 E 17TH ST
Practice Address - Street 2:SUITE D
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8042
Practice Address - Country:US
Practice Address - Phone:208-522-0747
Practice Address - Fax:855-830-4276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1374754Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER