Provider Demographics
NPI:1821129420
Name:STATE OF IDAHO
Entity Type:Organization
Organization Name:STATE OF IDAHO
Other - Org Name:SOUTHEASTERN DISTRICT HEALTH DEPARTMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:MARUGG
Authorized Official - Suffix:
Authorized Official - Credentials:REHS
Authorized Official - Phone:208-233-9080
Mailing Address - Street 1:1901 ALVIN RICKEN DR
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2727
Mailing Address - Country:US
Mailing Address - Phone:208-239-5242
Mailing Address - Fax:208-478-9297
Practice Address - Street 1:1901 ALVIN RICKEN DR
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2727
Practice Address - Country:US
Practice Address - Phone:208-239-5242
Practice Address - Fax:208-478-9297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002832700Medicaid