Provider Demographics
NPI:1275829376
Name:VAN DE GRIEND, PHILIP JON (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:JON
Last Name:VAN DE GRIEND
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 1:465 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4008
Mailing Address - Country:US
Mailing Address - Phone:208-234-4700
Mailing Address - Fax:
Practice Address - Street 1:465 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4008
Practice Address - Country:US
Practice Address - Phone:208-232-7862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-27
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAMD-42445207Q00000X
SCLL33736207Q00000X
NC2014-01351207Q00000X
IDM-15982207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNC2135Medicaid
NC1275829376Medicaid
SCNC2135Medicaid
NCNCK588BMedicare PIN
NC1275829376Medicaid