Provider Demographics
NPI:1194831339
Name:FAZZIO CLINIC PC
Entity Type:Organization
Organization Name:FAZZIO CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:J
Authorized Official - Last Name:FAZZIO
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:208-321-8600
Mailing Address - Street 1:7301 W EMERALD ST
Mailing Address - Street 2:STE 102
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8688
Mailing Address - Country:US
Mailing Address - Phone:208-321-8600
Mailing Address - Fax:208-321-8626
Practice Address - Street 1:7301 W EMERALD ST
Practice Address - Street 2:STE 102
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8688
Practice Address - Country:US
Practice Address - Phone:208-321-8600
Practice Address - Fax:208-321-8626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8H914OtherBLUE CROSS
ID1194831339OtherNPI
ID8H914OtherBLUE CROSS