Provider Demographics
NPI:1477014207
Name:IDAHO BARIATRIC AND METABOLIC INSTITUTE L.L.C.
Entity Type:Organization
Organization Name:IDAHO BARIATRIC AND METABOLIC INSTITUTE L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-378-4264
Mailing Address - Street 1:2960 E. ST. LUKE'S ST.
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-9005
Mailing Address - Country:US
Mailing Address - Phone:208-378-4264
Mailing Address - Fax:208-957-6891
Practice Address - Street 1:2960 E. ST. LUKE'S ST.
Practice Address - Street 2:SUITE 200
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-9005
Practice Address - Country:US
Practice Address - Phone:208-378-4264
Practice Address - Fax:208-957-6891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-26
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1184652364Medicaid