Provider Demographics
NPI:1376747790
Name:BOISE FAMILY MEDICINE CENTER
Entity Type:Organization
Organization Name:BOISE FAMILY MEDICINE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:L
Authorized Official - Last Name:MOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-377-3368
Mailing Address - Street 1:10798 W. OVERLAND RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-1329
Mailing Address - Country:US
Mailing Address - Phone:208-377-3368
Mailing Address - Fax:208-322-4691
Practice Address - Street 1:10798 W. OVERLAND RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-1329
Practice Address - Country:US
Practice Address - Phone:208-377-3368
Practice Address - Fax:208-322-4691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-11
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002643200Medicaid
ID32110OtherBLUE CROSS
ID000010006306OtherBLUE SHIELD
ID000010006306OtherBLUE SHIELD GROUP NUMBER
ID32110OtherBLUE CROSS GROUP NUMBER
ID000010006306OtherBLUE SHIELD GROUP NUMBER
ID32110OtherBLUE CROSS GROUP NUMBER