Provider Demographics
NPI:1417357534
Name:FPC PLLC
Entity Type:Organization
Organization Name:FPC PLLC
Other - Org Name:FOUR PEAKS CLINIC AND URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-690-8713
Mailing Address - Street 1:852 VALLEY CENTRE DR
Mailing Address - Street 2:
Mailing Address - City:DRIGGS
Mailing Address - State:ID
Mailing Address - Zip Code:83422-5005
Mailing Address - Country:US
Mailing Address - Phone:208-354-4757
Mailing Address - Fax:208-354-4758
Practice Address - Street 1:852 VALLEY CENTRE DR
Practice Address - Street 2:
Practice Address - City:DRIGGS
Practice Address - State:ID
Practice Address - Zip Code:83422-5005
Practice Address - Country:US
Practice Address - Phone:208-354-4757
Practice Address - Fax:208-354-4758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-26
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-7462261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDE32457Medicare UPIN
ID1377044Medicare PIN