Provider Demographics
NPI:1609412683
Name:MERIDIAN ADVANCED PSYCHIATRY , LLC
Entity Type:Organization
Organization Name:MERIDIAN ADVANCED PSYCHIATRY , LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:HULSEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-789-0202
Mailing Address - Street 1:1672 S WOODSAGE AVENUE
Mailing Address - Street 2:SUITE #120
Mailing Address - City:MERIDAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-515-2273
Mailing Address - Fax:208-515-2274
Practice Address - Street 1:1672 S WOODSAGE AVE.
Practice Address - Street 2:
Practice Address - City:MERIDAN
Practice Address - State:ID
Practice Address - Zip Code:83642
Practice Address - Country:US
Practice Address - Phone:208-515-2273
Practice Address - Fax:208-515-2274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-25
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Single Specialty