Provider Demographics
NPI:1417143926
Name:RICHARD RADNOVICH DO PC
Entity Type:Organization
Organization Name:RICHARD RADNOVICH DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:G
Authorized Official - Last Name:RADNOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:208-939-2100
Mailing Address - Street 1:4850 N ROSEPOINT WAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-5262
Mailing Address - Country:US
Mailing Address - Phone:208-939-2100
Mailing Address - Fax:208-939-4411
Practice Address - Street 1:4850 N ROSEPOINT WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-5262
Practice Address - Country:US
Practice Address - Phone:208-939-2100
Practice Address - Fax:208-939-4411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-18
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010139957OtherREGENCE BLUE SHIELD OF ID
IDS3978OtherBLUE CROSS OF IDAHO
ID1378887Medicare PIN