Provider Demographics
NPI:1194865444
Name:BOISE STATE HEALTH CENTER
Entity Type:Organization
Organization Name:BOISE STATE HEALTH CENTER
Other - Org Name:BOISE STATE UNIVERSITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROCHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLFE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-426-1470
Mailing Address - Street 1:1910 UNIVERSITY DR # MS -1351
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83725-1351
Mailing Address - Country:US
Mailing Address - Phone:208-426-2158
Mailing Address - Fax:208-426-1448
Practice Address - Street 1:1529 BELMONT ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83725-1351
Practice Address - Country:US
Practice Address - Phone:208-426-1459
Practice Address - Fax:208-426-3005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-7056261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health