Provider Demographics
NPI:1184657389
Name:TREASURE VALLEY CARDIOLOGY PC
Entity Type:Organization
Organization Name:TREASURE VALLEY CARDIOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GRAHAM
Authorized Official - Middle Name:
Authorized Official - Last Name:WETHERLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-322-1686
Mailing Address - Street 1:PO BOX 9589
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83707-4589
Mailing Address - Country:US
Mailing Address - Phone:208-472-8117
Mailing Address - Fax:208-472-8172
Practice Address - Street 1:900 N LIBERTY ST
Practice Address - Street 2:SUITE 302
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8704
Practice Address - Country:US
Practice Address - Phone:208-322-1686
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5449207RC0000X
IDNP642A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002180300Medicaid
ID807805900Medicaid
ID002180300Medicaid