Provider Demographics
NPI:1750498333
Name:DIGESTIVE HEALTH CLINIC LLC
Entity Type:Organization
Organization Name:DIGESTIVE HEALTH CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:MALLORY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-489-1900
Mailing Address - Street 1:6259 W EMERALD ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8731
Mailing Address - Country:US
Mailing Address - Phone:208-489-1900
Mailing Address - Fax:208-375-5286
Practice Address - Street 1:6259 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8731
Practice Address - Country:US
Practice Address - Phone:208-489-1900
Practice Address - Fax:208-375-5286
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807631700Medicaid
ID807631700Medicaid