Provider Demographics
NPI:1558641274
Name:OASIS PEDIATRICS
Entity Type:Organization
Organization Name:OASIS PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HUMPHREY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-602-2863
Mailing Address - Street 1:3217 W BAVARIA ST
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-5171
Mailing Address - Country:US
Mailing Address - Phone:208-602-2863
Mailing Address - Fax:208-947-3419
Practice Address - Street 1:3217 W BAVARIA ST
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-5171
Practice Address - Country:US
Practice Address - Phone:208-602-2863
Practice Address - Fax:208-947-3419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-25
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM9582208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID80673100Medicaid
ID80673100Medicaid