Provider Demographics
NPI:1750489647
Name:LALLY, RICHARD EMERY (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:EMERY
Last Name:LALLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11020 W AMITY RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-5051
Mailing Address - Country:US
Mailing Address - Phone:208-562-1664
Mailing Address - Fax:208-562-1565
Practice Address - Street 1:709 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:JEROME
Practice Address - State:ID
Practice Address - Zip Code:83338-1851
Practice Address - Country:US
Practice Address - Phone:208-324-4301
Practice Address - Fax:208-324-2224
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM8141207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
E22699Medicare UPIN
ID1101347Medicare ID - Type Unspecified