Provider Demographics
NPI:1043825219
Name:DISPATCHHEALTH-IDAHO PC
Entity type:Organization
Organization Name:DISPATCHHEALTH-IDAHO PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AO
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-589-4149
Mailing Address - Street 1:3825 N LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80205-3316
Mailing Address - Country:US
Mailing Address - Phone:303-904-7240
Mailing Address - Fax:
Practice Address - Street 1:4823 OLD KINGSTON PIKE STE 140
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-6473
Practice Address - Country:US
Practice Address - Phone:658-276-6969
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DISPATCHHEALTH - IDAHO PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-09-14
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty