Provider Demographics
NPI:1336490119
Name:IDAHO PATHOLOGY LABORATORY PHYSICIANS
Entity Type:Organization
Organization Name:IDAHO PATHOLOGY LABORATORY PHYSICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OF BUSINESS
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTOPHER
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCGEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FCAP
Authorized Official - Phone:208-690-0364
Mailing Address - Street 1:7069 RUNNING IRON LN
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-3816
Mailing Address - Country:US
Mailing Address - Phone:208-690-0364
Mailing Address - Fax:
Practice Address - Street 1:777 HOSPITAL WAY
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201
Practice Address - Country:US
Practice Address - Phone:208-232-7666
Practice Address - Fax:208-232-2334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-20
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM11025291U00000X
IDM11088291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory