Provider Demographics
NPI:1972673218
Name:KEITH E DAVIS
Entity Type:Organization
Organization Name:KEITH E DAVIS
Other - Org Name:SHOSHONE FAMILY MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:E
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-886-2224
Mailing Address - Street 1:PO BOX 609
Mailing Address - Street 2:
Mailing Address - City:SHOSHONE
Mailing Address - State:ID
Mailing Address - Zip Code:83352-0609
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:113 S APPLE ST
Practice Address - Street 2:
Practice Address - City:SHOSHONE
Practice Address - State:ID
Practice Address - Zip Code:83352-5287
Practice Address - Country:US
Practice Address - Phone:208-886-2222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806290300Medicaid
ID806290300Medicaid