Provider Demographics
NPI:1801838180
Name:SOUTHWEST IDAHO EAR, NOSE AND THROAT, PA
Entity Type:Organization
Organization Name:SOUTHWEST IDAHO EAR, NOSE AND THROAT, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PHARIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-367-3320
Mailing Address - Street 1:900 N LIBERTY ST
Mailing Address - Street 2:STE 400
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8704
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 STATE ST
Practice Address - Street 2:
Practice Address - City:MCCALL
Practice Address - State:ID
Practice Address - Zip Code:83638-3704
Practice Address - Country:US
Practice Address - Phone:208-367-3320
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1375149Medicare ID - Type Unspecified