Provider Demographics
NPI:1598822231
Name:ADVANCED FAMILY MEDICINE PLLC
Entity Type:Organization
Organization Name:ADVANCED FAMILY MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:FOUTZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-922-3355
Mailing Address - Street 1:943 LINDER RD
Mailing Address - Street 2:#103
Mailing Address - City:KUNA
Mailing Address - State:ID
Mailing Address - Zip Code:83634-3395
Mailing Address - Country:US
Mailing Address - Phone:208-922-3355
Mailing Address - Fax:208-922-9499
Practice Address - Street 1:943 LINDER RD
Practice Address - Street 2:#103
Practice Address - City:KUNA
Practice Address - State:ID
Practice Address - Zip Code:83634-3395
Practice Address - Country:US
Practice Address - Phone:208-922-3355
Practice Address - Fax:208-922-9499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806958500Medicaid
ID806958500Medicaid