Provider Demographics
NPI:1013956705
Name:SWANSON, JOEL C (MD)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:C
Last Name:SWANSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-302-6000
Mailing Address - Fax:208-302-6055
Practice Address - Street 1:323 E RIVERSIDE DR, SUITE 224
Practice Address - Street 2:SAMG EHP FAMILY MEDICINE
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6815
Practice Address - Country:US
Practice Address - Phone:208-302-6000
Practice Address - Fax:208-302-6055
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM8006207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805814100Medicaid
ID1143873Medicare ID - Type Unspecified
IDG07606Medicare UPIN