Provider Demographics
NPI:1588629406
Name:KOCEMBA, RUSSELL M (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:M
Last Name:KOCEMBA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-375-0862
Mailing Address - Fax:208-375-2658
Practice Address - Street 1:3301 N SAWGRASS WAY
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-4493
Practice Address - Country:US
Practice Address - Phone:208-375-0862
Practice Address - Fax:208-375-2658
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDM7077207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID11351202Medicare PIN