Provider Demographics
NPI:1245414028
Name:PHYSICIAN CENTER A PROFESSIONAL COMPANY MID LEVEL
Entity Type:Organization
Organization Name:PHYSICIAN CENTER A PROFESSIONAL COMPANY MID LEVEL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:J
Authorized Official - Last Name:MOFFITT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-814-8000
Mailing Address - Street 1:775 POLE LINE RD W
Mailing Address - Street 2:SUITE 105 & 111
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5814
Mailing Address - Country:US
Mailing Address - Phone:208-814-8000
Mailing Address - Fax:208-733-9402
Practice Address - Street 1:775 POLE LINE RD W
Practice Address - Street 2:SUITE 105 & 111
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5814
Practice Address - Country:US
Practice Address - Phone:208-814-8000
Practice Address - Fax:208-733-9402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-28
Last Update Date:2013-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8050368Medicaid