Provider Demographics
NPI:1952482440
Name:KOELSCH, MICHAEL PETER (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PETER
Last Name:KOELSCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 N 6TH EAST ST.
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:ID
Mailing Address - Zip Code:83647
Mailing Address - Country:US
Mailing Address - Phone:208-587-5880
Mailing Address - Fax:208-587-7905
Practice Address - Street 1:805 NORTH 6TH EAST
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647
Practice Address - Country:US
Practice Address - Phone:208-587-5880
Practice Address - Fax:208-587-7905
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM3819207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010001549OtherREGENCE BLUE SHIELD
ID57521OtherBLUE CROSS
IDB63403Medicare UPIN
ID000010001549OtherREGENCE BLUE SHIELD