Provider Demographics
NPI:1508345091
Name:INTEGRATED DERMATOLOGY OF IDAHO LLC
Entity Type:Organization
Organization Name:INTEGRATED DERMATOLOGY OF IDAHO LLC
Other - Org Name:GEM STATE DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:QUEEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-314-2000
Mailing Address - Street 1:4700 EXCHANGE CT STE 110
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-4450
Mailing Address - Country:US
Mailing Address - Phone:561-314-2000
Mailing Address - Fax:
Practice Address - Street 1:388 E PARKCENTER BLVD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-3942
Practice Address - Country:US
Practice Address - Phone:208-424-9101
Practice Address - Fax:208-424-5072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-07
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty