Provider Demographics
NPI:1710975057
Name:FRUITLAND ORTHOPEDIC CLINIC
Entity Type:Organization
Organization Name:FRUITLAND ORTHOPEDIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAN
Authorized Official - Middle Name:OLOF
Authorized Official - Last Name:DAHLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-452-2510
Mailing Address - Street 1:1118 NW 16TH ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:FRUITLAND
Mailing Address - State:ID
Mailing Address - Zip Code:83619-2271
Mailing Address - Country:US
Mailing Address - Phone:208-452-2510
Mailing Address - Fax:208-452-2513
Practice Address - Street 1:1118 NW 16TH ST
Practice Address - Street 2:SUITE C
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-2271
Practice Address - Country:US
Practice Address - Phone:208-452-2510
Practice Address - Fax:208-452-2513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-6608207X00000X
ORMD13079207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR266148Medicaid
IDC92468Medicare UPIN
OR121747Medicare ID - Type UnspecifiedINDIVIDUAL NUMBER
ID1140903Medicare ID - Type UnspecifiedPROVIDER NUMBER