Provider Demographics
NPI:1972545556
Name:FAMILY MEDICAL CENTER PLLC
Entity Type:Organization
Organization Name:FAMILY MEDICAL CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:DRAKE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:208-414-1124
Mailing Address - Street 1:360 E LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:WEISER
Mailing Address - State:ID
Mailing Address - Zip Code:83672-2261
Mailing Address - Country:US
Mailing Address - Phone:208-414-1124
Mailing Address - Fax:208-414-0947
Practice Address - Street 1:360 E LIBERTY ST
Practice Address - Street 2:
Practice Address - City:WEISER
Practice Address - State:ID
Practice Address - Zip Code:83672-2261
Practice Address - Country:US
Practice Address - Phone:208-414-1124
Practice Address - Fax:208-414-0947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8006347400Medicaid
ORR135455OtherMEDICARE PART B
ID1369418OtherMEDICARE PART B