Provider Demographics
NPI:1477501930
Name:CDS,PA
Entity Type:Organization
Organization Name:CDS,PA
Other - Org Name:POCATELLO WOMEN'S HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:A
Authorized Official - Last Name:DYER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-232-3252
Mailing Address - Street 1:777 HOSPITAL WAY
Mailing Address - Street 2:BLDG A, STE 300
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5175
Mailing Address - Country:US
Mailing Address - Phone:208-239-3453
Mailing Address - Fax:208-239-3403
Practice Address - Street 1:777 HOSPITAL WAY
Practice Address - Street 2:BLDG A, STE 300
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5175
Practice Address - Country:US
Practice Address - Phone:208-232-6100
Practice Address - Fax:208-239-3403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8N201OtherBLUE CROSS
ID805212100Medicaid
IDCI7480OtherRAILROAD MEDICARE
ID002374200Medicaid
IDCI7480OtherRAILROAD MEDICARE