Provider Demographics
NPI:1497949705
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:KATE
Authorized Official - Middle Name:A
Authorized Official - Last Name:SHELTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-287-6558
Mailing Address - Street 1:PO BOX 1128
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83701-1128
Mailing Address - Country:US
Mailing Address - Phone:208-489-4016
Mailing Address - Fax:208-489-4015
Practice Address - Street 1:3551 E OVERLAND ROAD
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:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IDAHO PHYSICIAL MEDICINE AND REHABILITATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-29
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2081P2900X
ID261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808002500Medicaid
IDP00612157OtherRAILROAD MEDICARE
IDP00612157OtherRAILROAD MEDICARE