Provider Demographics
NPI:1215025648
Name:GERLACH, PAUL A (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:A
Last Name:GERLACH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2985 CORTEZ AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7554
Mailing Address - Country:US
Mailing Address - Phone:208-523-3373
Mailing Address - Fax:208-523-8746
Practice Address - Street 1:2985 CORTEZ AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7554
Practice Address - Country:US
Practice Address - Phone:208-523-3373
Practice Address - Fax:208-523-8746
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD14220207RC0000X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1215025648OtherNPI
1215025648OtherNPI
A98962Medicare UPIN