Provider Demographics
NPI:1659540292
Name:POCATELLO CARDIOLOGY ASSOCIATES
Entity Type:Organization
Organization Name:POCATELLO CARDIOLOGY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINSTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:P
Authorized Official - Last Name:CONOLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-234-2001
Mailing Address - Street 1:PO BOX O
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83205-0049
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:777 HOSPITAL WAY BLDG A
Practice Address - Street 2:STE. 101
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2753
Practice Address - Country:US
Practice Address - Phone:208-234-2001
Practice Address - Fax:208-232-2195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-28
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806402400Medicaid