Provider Demographics
NPI:1639117153
Name:BOISE DERMAESTHETICS, LLC
Entity Type:Organization
Organization Name:BOISE DERMAESTHETICS, LLC
Other - Org Name:MCCONNEHEY FAMILY MEDICINE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:BILLING MANGER
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:D
Authorized Official - Last Name:LUNDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-452-6794
Mailing Address - Street 1:6126 W EMERALD ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8857
Mailing Address - Country:US
Mailing Address - Phone:208-323-6525
Mailing Address - Fax:
Practice Address - Street 1:6126 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8857
Practice Address - Country:US
Practice Address - Phone:208-323-6525
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1504891Medicare ID - Type Unspecified