Provider Demographics
NPI:1376662486
Name:TWO RIVERS MEDICAL CLINIC, PA
Entity Type:Organization
Organization Name:TWO RIVERS MEDICAL CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TONY
Authorized Official - Middle Name:
Authorized Official - Last Name:EDMONDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-549-0211
Mailing Address - Street 1:PO BOX 871
Mailing Address - Street 2:
Mailing Address - City:WEISER
Mailing Address - State:ID
Mailing Address - Zip Code:83672-0001
Mailing Address - Country:US
Mailing Address - Phone:208-549-0211
Mailing Address - Fax:208-549-0104
Practice Address - Street 1:683 E 3RD ST
Practice Address - Street 2:
Practice Address - City:WEISER
Practice Address - State:ID
Practice Address - Zip Code:83672-2248
Practice Address - Country:US
Practice Address - Phone:208-549-0211
Practice Address - Fax:208-549-0104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002756300Medicaid
ID805040300Medicaid
ID002756600Medicaid
ID1376662486Medicaid
ID002756300Medicaid
ID133836Medicare Oscar/Certification
ID1373810Medicare ID - Type Unspecified