Provider Demographics
NPI:1477671477
Name:POCATELLO CLINIC OF INTERNAL MEDICINE PA
Entity Type:Organization
Organization Name:POCATELLO CLINIC OF INTERNAL MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:P
Authorized Official - Last Name:BENSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-233-4562
Mailing Address - Street 1:PO BOX 880
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204
Mailing Address - Country:US
Mailing Address - Phone:208-233-4562
Mailing Address - Fax:208-234-4638
Practice Address - Street 1:707 N 7TH
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201
Practice Address - Country:US
Practice Address - Phone:208-233-4562
Practice Address - Fax:208-234-4638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID29296OtherGROUP BLUE SHIELD
IDCP9190OtherGROUP RAILROAD MEDICARE
ID88765OtherGROUP BLUE CROSS
ID29296OtherGROUP BLUE SHIELD