Provider Demographics
NPI:1639516180
Name:W ALLEN RADER, MD PC
Entity Type:Organization
Organization Name:W ALLEN RADER, MD PC
Other - Org Name:IDAHO WEIGHT LOSS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILBUR
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:RADER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-343-3652
Mailing Address - Street 1:801 N STILSON RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-5145
Mailing Address - Country:US
Mailing Address - Phone:208-343-3652
Mailing Address - Fax:208-367-9188
Practice Address - Street 1:801 N STILSON RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703-5145
Practice Address - Country:US
Practice Address - Phone:208-343-3652
Practice Address - Fax:208-367-9188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-23
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7878207RB0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RB0002XAllopathic & Osteopathic PhysiciansInternal MedicineObesity MedicineGroup - Single Specialty