Provider Demographics
NPI:1497969604
Name:IDAHO PHYSICAL MEDICINE & REHABILITATION
Entity Type:Organization
Organization Name:IDAHO PHYSICAL MEDICINE & REHABILITATION
Other - Org Name:PA GRP
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:A
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-489-5160
Mailing Address - Street 1:600 N. ROBBINS RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702
Mailing Address - Country:US
Mailing Address - Phone:208-489-4016
Mailing Address - Fax:208-489-4015
Practice Address - Street 1:600 ROBBINS RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4539
Practice Address - Country:US
Practice Address - Phone:208-489-4016
Practice Address - Fax:208-489-4015
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IDAHO PHYSICAL MEDICINE & REHABILITATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-09
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID80746780Medicaid