Provider Demographics
NPI:1760774483
Name:MATTHEW R SERICATI, M.D. CHARTERED
Entity Type:Organization
Organization Name:MATTHEW R SERICATI, M.D. CHARTERED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:R
Authorized Official - Last Name:SERICATI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-343-1702
Mailing Address - Street 1:425 W BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6035
Mailing Address - Country:US
Mailing Address - Phone:208-343-1702
Mailing Address - Fax:208-342-7042
Practice Address - Street 1:425 W BANNOCK ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6035
Practice Address - Country:US
Practice Address - Phone:208-343-1702
Practice Address - Fax:208-342-7042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-13
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM10669207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1194871871OtherINDIVIDUAL NPI