Provider Demographics
NPI:1508034802
Name:MARC BOSTICK MD CHARTERED
Entity Type:Organization
Organization Name:MARC BOSTICK MD CHARTERED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALER
Authorized Official - Prefix:
Authorized Official - First Name:CHERI
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-954-5594
Mailing Address - Street 1:413 N ALLUMBAUGH ST
Mailing Address - Street 2:STE 101
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9219
Mailing Address - Country:US
Mailing Address - Phone:208-323-1125
Mailing Address - Fax:208-323-9604
Practice Address - Street 1:413 N ALLUMBAUGH ST
Practice Address - Street 2:STE 101
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9219
Practice Address - Country:US
Practice Address - Phone:208-323-1125
Practice Address - Fax:208-323-9604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-20
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM77122084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1378593Medicare PIN