Provider Demographics
NPI:1982037727
Name:JON-ERIC BAILLIE, MD PLLC
Entity Type:Organization
Organization Name:JON-ERIC BAILLIE, MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JANENE
Authorized Official - Middle Name:
Authorized Official - Last Name:RAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:208-377-3299
Mailing Address - Street 1:8100 W EMERALD ST STE 180
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9069
Mailing Address - Country:US
Mailing Address - Phone:208-377-3299
Mailing Address - Fax:208-460-5227
Practice Address - Street 1:8100 W EMERALD ST STE 180
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704
Practice Address - Country:US
Practice Address - Phone:208-377-3299
Practice Address - Fax:208-460-5227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-15
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-7882207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDM-7882OtherIDAHO MEDICAL LICENSE