Provider Demographics
NPI:1891025334
Name:HIGH VALLEY DERMATOLOGY & DERMATOLOGIC SURGERY LLC
Entity Type:Organization
Organization Name:HIGH VALLEY DERMATOLOGY & DERMATOLOGIC SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LINDSAY
Authorized Official - Middle Name:D
Authorized Official - Last Name:SEWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-525-4888
Mailing Address - Street 1:2085 PROVIDENCE WAY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-4945
Mailing Address - Country:US
Mailing Address - Phone:208-525-4888
Mailing Address - Fax:208-525-4885
Practice Address - Street 1:2085 PROVIDENCE WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-4945
Practice Address - Country:US
Practice Address - Phone:208-525-4888
Practice Address - Fax:208-525-4885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-06
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM10198207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty