Provider Demographics
NPI:1275715757
Name:PANHANDLE EYE CLINICS CHARTERED
Entity Type:Organization
Organization Name:PANHANDLE EYE CLINICS CHARTERED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:D
Authorized Official - Last Name:MAGWIRE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-245-6563
Mailing Address - Street 1:704 W COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:ST MARIES
Mailing Address - State:ID
Mailing Address - Zip Code:83861-1824
Mailing Address - Country:US
Mailing Address - Phone:208-245-6563
Mailing Address - Fax:208-245-6564
Practice Address - Street 1:704 W COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:ST MARIES
Practice Address - State:ID
Practice Address - Zip Code:83861-1824
Practice Address - Country:US
Practice Address - Phone:208-245-6563
Practice Address - Fax:208-245-6564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-27
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODD382332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDV0179OtherBLUE CROSS OF IDAHO
ID0000100159391OtherREGENCE BLUESHIELD
ID002692300Medicaid
ID0225150001Medicare NSC
ID1590601Medicare PIN
ID002692300Medicaid