Provider Demographics
NPI:1992032098
Name:PHS MD #1, LLC
Entity Type:Organization
Organization Name:PHS MD #1, LLC
Other - Org Name:POCATELLO FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:ABREU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-239-2110
Mailing Address - Street 1:PO BOX 4728
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83205-4728
Mailing Address - Country:US
Mailing Address - Phone:208-239-2110
Mailing Address - Fax:208-239-2145
Practice Address - Street 1:465 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4008
Practice Address - Country:US
Practice Address - Phone:208-239-2110
Practice Address - Fax:208-239-2145
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:POCATELLO HEALTH SERVICES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-11-10
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care