Provider Demographics
NPI:1922366707
Name:COTTONWOOD FAMILY MEDICINE
Entity Type:Organization
Organization Name:COTTONWOOD FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARCIA
Authorized Official - Middle Name:DEE
Authorized Official - Last Name:PRICE-MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-995-2875
Mailing Address - Street 1:100 COTTONWOOD COURT
Mailing Address - Street 2:SUITE 150
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83616
Mailing Address - Country:US
Mailing Address - Phone:208-995-2875
Mailing Address - Fax:208-995-2874
Practice Address - Street 1:100 COTTONWOOD COURT
Practice Address - Street 2:SUITE 150
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:87616
Practice Address - Country:US
Practice Address - Phone:208-995-2875
Practice Address - Fax:208-995-2874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-30
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003874400Medicaid
51276OtherBLUE CROSS
51276OtherBLUE CROSS
1134498Medicare Oscar/Certification