Provider Demographics
NPI:1386683431
Name:REES, CAROLYN (MD)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:REES
Suffix:
Gender:F
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:PO BOX 277976
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-7976
Mailing Address - Country:US
Mailing Address - Phone:208-459-4667
Mailing Address - Fax:208-459-3372
Practice Address - Street 1:211 E LOGAN ST
Practice Address - Street 2:SUITE 303
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-0000
Practice Address - Country:US
Practice Address - Phone:208-459-4667
Practice Address - Fax:208-459-3372
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2009-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7111207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010002266OtherBLUE SHIELD
ID804151800Medicaid
ID804151800Medicaid
ID000010002266OtherBLUE SHIELD
P00399248Medicare PIN