Provider Demographics
NPI:1972808806
Name:PSYCHIATRY-ECT, PLLC
Entity Type:Organization
Organization Name:PSYCHIATRY-ECT, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PREDRAG
Authorized Official - Middle Name:V
Authorized Official - Last Name:GLIGOROVIC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-233-8344
Mailing Address - Street 1:285 VISTA DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201
Mailing Address - Country:US
Mailing Address - Phone:208-233-8344
Mailing Address - Fax:208-233-6983
Practice Address - Street 1:285 VISTA DR
Practice Address - Street 2:SUITE D
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201
Practice Address - Country:US
Practice Address - Phone:208-233-8344
Practice Address - Fax:208-233-6983
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-25
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-96002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty