Provider Demographics
NPI:1275729261
Name:WESTERN IDAHO PATHOLOGY PA
Entity Type:Organization
Organization Name:WESTERN IDAHO PATHOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:R
Authorized Official - Last Name:EASTMAN
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:208-455-3799
Mailing Address - Street 1:PO BOX 49009
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29649-0001
Mailing Address - Country:US
Mailing Address - Phone:864-223-3070
Mailing Address - Fax:864-223-1396
Practice Address - Street 1:1717 ARLINGTON AVE
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4802
Practice Address - Country:US
Practice Address - Phone:208-455-3799
Practice Address - Fax:310-698-7040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-24
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8078528Medicaid
ID8078528Medicaid
ID11305172Medicare PIN