Provider Demographics
NPI:1790872109
Name:WALKER SPINE AND SPORTS SPECIALISTS
Entity Type:Organization
Organization Name:WALKER SPINE AND SPORTS SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:C
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-227-1200
Mailing Address - Street 1:2319 CORONADO ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7407
Mailing Address - Country:US
Mailing Address - Phone:208-227-1200
Mailing Address - Fax:208-227-1212
Practice Address - Street 1:2319 CORONADO ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7407
Practice Address - Country:US
Practice Address - Phone:208-227-1200
Practice Address - Fax:208-227-1212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDE65389204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010140195OtherREGENCE BLUE SHIELD
ID204221200OtherUS DEPT OF LABOR
ID8H989OtherBLUE CROSS
IDDA4495OtherRAILROAD MEDICARE
ID806811100Medicaid
IDDA4495OtherRAILROAD MEDICARE