Provider Demographics
NPI:1407826167
Name:AGRUSA, PHILLIP C (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:C
Last Name:AGRUSA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3520 E. LOUISE DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-955-0350
Mailing Address - Fax:208-955-0352
Practice Address - Street 1:3520 E. LOUISE DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642
Practice Address - Country:US
Practice Address - Phone:208-955-0350
Practice Address - Fax:208-955-0352
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAM7716207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805522900Medicaid
ID000010005656OtherREGENCE BLUE SHIELD OF ID
OR212843Medicaid
IDJ1742OtherBLUE CROSS OF IDAHO
IDH27312Medicare UPIN
ID000010005656OtherREGENCE BLUE SHIELD OF ID