Provider Demographics
NPI:1609004597
Name:EAGLE INTERNAL MEDICINE, PLLC
Entity Type:Organization
Organization Name:EAGLE INTERNAL MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:PATMAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-938-0090
Mailing Address - Street 1:1025 S. BRIDGEWAY PL.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616
Mailing Address - Country:US
Mailing Address - Phone:208-938-0090
Mailing Address - Fax:208-938-0918
Practice Address - Street 1:1025 S BRIDGE WAY PL
Practice Address - Street 2:SUITE 100
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6834
Practice Address - Country:US
Practice Address - Phone:208-938-0090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-30
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM10058207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C55688OtherUPIN