Provider Demographics
NPI:1619038346
Name:ADULT AND GERIATRIC MEDICAL CARE, P.C.
Entity Type:Organization
Organization Name:ADULT AND GERIATRIC MEDICAL CARE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MELCHIORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-651-1092
Mailing Address - Street 1:PO BOX 238
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-0238
Mailing Address - Country:US
Mailing Address - Phone:208-651-1092
Mailing Address - Fax:877-234-0633
Practice Address - Street 1:2003 LINCOLN WAY
Practice Address - Street 2:KMC MED STAFF OFFICE
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2611
Practice Address - Country:US
Practice Address - Phone:208-651-1092
Practice Address - Fax:877-234-0633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1374708Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER