Provider Demographics
NPI:1508866260
Name:EASTERN IDAHO CARDIOLOGY ASSOCIATES, PLLC
Entity Type:Organization
Organization Name:EASTERN IDAHO CARDIOLOGY ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:D
Authorized Official - Last Name:GORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-524-2255
Mailing Address - Street 1:2001 S WOODRUFF AVE
Mailing Address - Street 2:SUITE 12A
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6374
Mailing Address - Country:US
Mailing Address - Phone:208-524-2255
Mailing Address - Fax:208-524-2256
Practice Address - Street 1:2001 S WOODRUFF AVE
Practice Address - Street 2:SUITE 12A
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6374
Practice Address - Country:US
Practice Address - Phone:208-524-2255
Practice Address - Fax:208-524-2256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805326000Medicaid
1375782Medicare ID - Type Unspecified