Provider Demographics
NPI:1720362775
Name:GEM FAMILY MEDICINE LLC
Entity Type:Organization
Organization Name:GEM FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:VERNALEE
Authorized Official - Last Name:MARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-365-3455
Mailing Address - Street 1:1108 SOUTH WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:EMMETT
Mailing Address - State:ID
Mailing Address - Zip Code:83617-3535
Mailing Address - Country:US
Mailing Address - Phone:208-365-3455
Mailing Address - Fax:208-365-3422
Practice Address - Street 1:1108 SOUTH WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-3535
Practice Address - Country:US
Practice Address - Phone:208-365-3455
Practice Address - Fax:208-365-3422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-07
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-701A207Q00000X
IDN-33941207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty