Provider Demographics
NPI:1821164138
Name:THE SHOULDER CLINIC OF IDAHO PLLC
Entity Type:Organization
Organization Name:THE SHOULDER CLINIC OF IDAHO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:EARL
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-323-4747
Mailing Address - Street 1:1940 S BONITO WAY STE 190
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-5618
Mailing Address - Country:US
Mailing Address - Phone:208-287-9420
Mailing Address - Fax:
Practice Address - Street 1:8854 W EMERALD ST
Practice Address - Street 2:STE 102
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-4844
Practice Address - Country:US
Practice Address - Phone:208-323-4747
Practice Address - Fax:208-323-4848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1370261Medicare ID - Type Unspecified