Provider Demographics
NPI:1992853386
Name:GEM STATE PEDIATRICS
Entity Type:Organization
Organization Name:GEM STATE PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-706-5460
Mailing Address - Street 1:520 S EAGLE RD
Mailing Address - Street 2:SUITE 1209
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6308
Mailing Address - Country:US
Mailing Address - Phone:208-706-5460
Mailing Address - Fax:208-706-5465
Practice Address - Street 1:520 S EAGLE RD
Practice Address - Street 2:SUITE 1209
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6308
Practice Address - Country:US
Practice Address - Phone:208-706-5460
Practice Address - Fax:208-706-5465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5562208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID57885OtherBLUE CROSS OF IDAHO
ID000010001341OtherBLUE SHIELD OF IDAHO
ID000010001341OtherBLUE SHIELD OF IDAHO