Provider Demographics
NPI:1780032326
Name:IDAHO STATE UNIVERSITY DEPARTMENT OF FAMILY MEDICINE
Entity Type:Organization
Organization Name:IDAHO STATE UNIVERSITY DEPARTMENT OF FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZATION SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-232-6260
Mailing Address - Street 1:1000 N 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5757
Mailing Address - Country:US
Mailing Address - Phone:208-232-6260
Mailing Address - Fax:208-232-6259
Practice Address - Street 1:465 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4008
Practice Address - Country:US
Practice Address - Phone:208-282-4141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HEALTH WEST INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-05-24
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health