Provider Demographics
NPI:1497766240
Name:POCATELLO PULMONARY PC
Entity Type:Organization
Organization Name:POCATELLO PULMONARY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARY
Authorized Official - Middle Name:V
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-233-5864
Mailing Address - Street 1:500 S 11TH AVE
Mailing Address - Street 2:SUITE 305
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4835
Mailing Address - Country:US
Mailing Address - Phone:208-233-5864
Mailing Address - Fax:
Practice Address - Street 1:500 S 11TH AVE
Practice Address - Street 2:SUITE 305
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4835
Practice Address - Country:US
Practice Address - Phone:208-233-5864
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5647207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty