Provider Demographics
NPI:1134620107
Name:FAMILY MEDICINE HUB PLLC
Entity type:Organization
Organization Name:FAMILY MEDICINE HUB PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMERON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-357-4633
Mailing Address - Street 1:2001 S WOODRUFF AVE STE 15B
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6372
Mailing Address - Country:US
Mailing Address - Phone:208-357-4633
Mailing Address - Fax:208-419-0690
Practice Address - Street 1:2001 S WOODRUFF AVE STE 15B
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6372
Practice Address - Country:US
Practice Address - Phone:208-357-4633
Practice Address - Fax:208-419-0690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-26
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1629128483Medicaid