Provider Demographics
NPI:1689620692
Name:IDAHO UROLOGIC INSTITUTE PA
Entity Type:Organization
Organization Name:IDAHO UROLOGIC INSTITUTE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:WALDAMANN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-343-7736
Mailing Address - Street 1:2855 E MAGIC VIEW DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6245
Mailing Address - Country:US
Mailing Address - Phone:208-639-4900
Mailing Address - Fax:208-639-4939
Practice Address - Street 1:2855 E MAGIC VIEW DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6245
Practice Address - Country:US
Practice Address - Phone:208-639-4900
Practice Address - Fax:208-639-4939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807277400Medicaid
ID8M783OtherBLUE CROSS NAMPA
IDDD7372OtherRAILROAD MEDICARE
ID8M152OtherBLUE CROSS BOISE
ID000010006729OtherBLUE SHIELD MERIDIAN
ID000010152026OtherBLUE SHIELD NAMPA
ID8M879OtherBLUE CROSS MERIDIAN
ID000010152026OtherBLUE SHIELD BOISE