Provider Demographics
NPI:1710053756
Name:EAGLE ROCK REGIONAL NEUROLOGY, P.C.
Entity Type:Organization
Organization Name:EAGLE ROCK REGIONAL NEUROLOGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:KARL
Authorized Official - Last Name:DOMARAD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:208-552-5700
Mailing Address - Street 1:1995 E 17TH ST
Mailing Address - Street 2:STE 5
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6493
Mailing Address - Country:US
Mailing Address - Phone:208-552-5700
Mailing Address - Fax:208-552-5703
Practice Address - Street 1:1995 E 17TH ST
Practice Address - Street 2:STE 5
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6493
Practice Address - Country:US
Practice Address - Phone:208-552-5700
Practice Address - Fax:208-552-5703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO3432084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDS5247OtherBLUE CROSS
ID1378089Medicare ID - Type Unspecified
IDS5247OtherBLUE CROSS