Provider Demographics
NPI:1508918244
Name:STAR MEDICAL CENTER PC
Entity Type:Organization
Organization Name:STAR MEDICAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELMER
Authorized Official - Middle Name:G
Authorized Official - Last Name:DODGE
Authorized Official - Suffix:JR
Authorized Official - Credentials:RNP
Authorized Official - Phone:208-286-0666
Mailing Address - Street 1:PO BOX 44267
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83711-0267
Mailing Address - Country:US
Mailing Address - Phone:208-286-0666
Mailing Address - Fax:208-286-0565
Practice Address - Street 1:9858 W STATE ST
Practice Address - Street 2:
Practice Address - City:STAR
Practice Address - State:ID
Practice Address - Zip Code:83669-5210
Practice Address - Country:US
Practice Address - Phone:208-286-0666
Practice Address - Fax:208-286-0565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8L030OtherBLUE CROSS OF ID
ID807071100Medicaid
ID807071100Medicaid