Provider Demographics
NPI:1831285857
Name:BOISE BASIN INFERTILITY & GYNECOLOGY, P.A.
Entity Type:Organization
Organization Name:BOISE BASIN INFERTILITY & GYNECOLOGY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:M
Authorized Official - Last Name:KRUEGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-345-2006
Mailing Address - Street 1:811 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-5545
Mailing Address - Country:US
Mailing Address - Phone:208-345-2006
Mailing Address - Fax:208-345-1408
Practice Address - Street 1:811 N 6TH ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-5545
Practice Address - Country:US
Practice Address - Phone:208-345-2006
Practice Address - Fax:208-345-1408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-3549174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002515100Medicaid
ID002515101Medicaid
IDDK093OtherBLUE CROSS
ID000010004456OtherBLUE SHIELD
ID002515102Medicaid
ID1111231Medicare ID - Type Unspecified
ID002515101Medicaid
ID1111232Medicare ID - Type Unspecified
ID1111230Medicare ID - Type Unspecified
ID002515100Medicaid