Provider Demographics
NPI:1477558328
Name:BRYAN C POGUE MD
Entity Type:Organization
Organization Name:BRYAN C POGUE MD
Other - Org Name:SELAH MEDICAL CENTER, PA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:M
Authorized Official - Last Name:SIZEMORE
Authorized Official - Suffix:
Authorized Official - Credentials:CMPE
Authorized Official - Phone:208-377-5055
Mailing Address - Street 1:6565 W EMERALD ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8737
Mailing Address - Country:US
Mailing Address - Phone:208-377-5055
Mailing Address - Fax:208-377-5335
Practice Address - Street 1:6565 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8737
Practice Address - Country:US
Practice Address - Phone:208-377-5055
Practice Address - Fax:208-377-5335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-16
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5125207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002789800Medicaid
ID002789800Medicaid