Provider Demographics
NPI:1356475115
Name:MICHAEL P KOELSCH MD
Entity Type:Organization
Organization Name:MICHAEL P KOELSCH MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY LOU
Authorized Official - Middle Name:
Authorized Official - Last Name:KOELSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-587-5880
Mailing Address - Street 1:PO BOX 940
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:ID
Mailing Address - Zip Code:83647-0940
Mailing Address - Country:US
Mailing Address - Phone:208-587-5880
Mailing Address - Fax:208-587-7905
Practice Address - Street 1:805 N 6TH E
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647-2207
Practice Address - Country:US
Practice Address - Phone:208-587-5880
Practice Address - Fax:208-587-7905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM3819207R00000X
IDNP382A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8H732OtherBLUE CROSS GROUP
ID805234300Medicaid
ID1375955Medicare ID - Type UnspecifiedGROUP