Provider Demographics
NPI:1407894041
Name:BRUCE C MCCOMAS, M. D., P. A.
Entity Type:Organization
Organization Name:BRUCE C MCCOMAS, M. D., P. A.
Other - Org Name:SOUTHERN IDAHO VEIN CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:C
Authorized Official - Last Name:MCCOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-734-3596
Mailing Address - Street 1:PO BOX 587
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83303-0587
Mailing Address - Country:US
Mailing Address - Phone:208-814-7400
Mailing Address - Fax:208-814-7491
Practice Address - Street 1:775 POLE LINE RD W
Practice Address - Street 2:SUITE 212
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5814
Practice Address - Country:US
Practice Address - Phone:208-814-8400
Practice Address - Fax:208-734-3045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2013-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5070208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000369200Medicaid
ID020048945OtherRR MEDICARE
ID000369200Medicaid