Provider Demographics
NPI:1023073897
Name:ARCHIE, THOMAS E JR (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:E
Last Name:ARCHIE
Suffix:JR
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 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:
Practice Address - Street 1:1450 AVIATION DR
Practice Address - Street 2:SUITE 100
Practice Address - City:HAILEY
Practice Address - State:ID
Practice Address - Zip Code:83333-8785
Practice Address - Country:US
Practice Address - Phone:208-788-3434
Practice Address - Fax:208-788-2025
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM10114207Q00000X, 171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP00697901OtherMCRR
ID807891600Medicaid
IDP00697901OtherMCRR
ID11001051Medicare PIN
ID20001826Medicare PIN