Provider Demographics
NPI:1659687812
Name:MATRIX MEDICAL NETWORK OF IDAHO, L.L.C
Entity Type:Organization
Organization Name:MATRIX MEDICAL NETWORK OF IDAHO, L.L.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:R
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-464-5200
Mailing Address - Street 1:4545 E SHEA BLVD
Mailing Address - Street 2:SUITE 175
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-3074
Mailing Address - Country:US
Mailing Address - Phone:602-464-5200
Mailing Address - Fax:
Practice Address - Street 1:4545 E SHEA BLVD
Practice Address - Street 2:SUITE 175
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-3074
Practice Address - Country:US
Practice Address - Phone:602-464-5200
Practice Address - Fax:480-907-2108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-26
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty