Provider Demographics
NPI:1649225616
Name:CALDWELL INTERNAL MEDICINE PROFESSIONAL ASSOCIATION
Entity Type:Organization
Organization Name:CALDWELL INTERNAL MEDICINE PROFESSIONAL ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:KOGA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-459-4667
Mailing Address - Street 1:211 E LOGAN ST
Mailing Address - Street 2:SUITE 303
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-4835
Mailing Address - Country:US
Mailing Address - Phone:208-459-4667
Mailing Address - Fax:208-459-3372
Practice Address - Street 1:211 E LOGAN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4835
Practice Address - Country:US
Practice Address - Phone:208-459-4667
Practice Address - Fax:208-459-3372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1370106Medicare ID - Type Unspecified
ID1366301Medicare PIN