Provider Demographics
NPI:1497711329
Name:IDAHO PHYSICAL MEDICINE AND REHABILITATION PA
Entity Type:Organization
Organization Name:IDAHO PHYSICAL MEDICINE AND REHABILITATION PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:MECHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-884-1333
Mailing Address - Street 1:PO BOX 1128
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83701
Mailing Address - Country:US
Mailing Address - Phone:208-884-1333
Mailing Address - Fax:208-489-4015
Practice Address - Street 1:3551 E. OVERLAND RD.
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642
Practice Address - Country:US
Practice Address - Phone:208-884-1333
Practice Address - Fax:208-489-4015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-20
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID208100000X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1373378Medicare PIN
ORR121283Medicare PIN
CS2444Medicare PIN