Provider Demographics
NPI:1578508081
Name:IDAHO STATE UNIVERSITY
Entity Type:Organization
Organization Name:IDAHO STATE UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUDIOLOGIST
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BISHOP
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:208-282-3495
Mailing Address - Street 1:650 MEMORIAL DRIVE
Mailing Address - Street 2:# 68
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83209-0001
Mailing Address - Country:US
Mailing Address - Phone:208-282-3495
Mailing Address - Fax:208-282-4571
Practice Address - Street 1:650 MEMORIAL DRIVE
Practice Address - Street 2:# 68
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83209-0001
Practice Address - Country:US
Practice Address - Phone:208-282-3495
Practice Address - Fax:208-282-4571
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAUD1225231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1580319Medicare ID - Type Unspecified