Provider Demographics
NPI:1730126566
Name:SNAKE RIVER UROLOGY, P.C.
Entity Type:Organization
Organization Name:SNAKE RIVER UROLOGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:BOWYER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-732-3040
Mailing Address - Street 1:660 SHOSHONE ST E
Mailing Address - Street 2:SUITE 201
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-6110
Mailing Address - Country:US
Mailing Address - Phone:208-732-3040
Mailing Address - Fax:208-732-3195
Practice Address - Street 1:660 SHOSHONE ST E
Practice Address - Street 2:SUITE 201
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-6110
Practice Address - Country:US
Practice Address - Phone:208-732-3040
Practice Address - Fax:208-732-3195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805710000Medicaid
ID340019783OtherRR MEDICARE
ID805710000Medicaid
ID1370078Medicare ID - Type UnspecifiedMEDICARE NUMBER