Provider Demographics
NPI:1588832992
Name:IDAHO PAIN MEDICINE, LLP
Entity Type:Organization
Organization Name:IDAHO PAIN MEDICINE, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:MAXWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:208-323-6273
Mailing Address - Street 1:8950 W EMERALD ST STE 168
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8296
Mailing Address - Country:US
Mailing Address - Phone:208-323-6273
Mailing Address - Fax:208-323-6277
Practice Address - Street 1:8950 W EMERALD ST STE 168
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8296
Practice Address - Country:US
Practice Address - Phone:208-323-6273
Practice Address - Fax:208-323-6277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-19
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty