Provider Demographics
NPI:1780649863
Name:EGBERT, PAUL S (DC)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:S
Last Name:EGBERT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:479 POLK ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-4850
Mailing Address - Country:US
Mailing Address - Phone:208-736-0343
Mailing Address - Fax:208-736-0890
Practice Address - Street 1:479 POLK ST
Practice Address - Street 2:SUITE A
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-4850
Practice Address - Country:US
Practice Address - Phone:208-736-0343
Practice Address - Fax:208-736-0890
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-662111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDC6634OtherBLUE CROSS
ID002707300Medicaid
ID000010019915OtherREGENCE
IDU41855Medicare UPIN
ID002707300Medicaid
IDC6634OtherBLUE CROSS
ID1672799Medicare ID - Type UnspecifiedINDIVIDUAL