Provider Demographics
NPI:1184255754
Name:IDAHO MODERN MEDICINE - PLLC
Entity type:Organization
Organization Name:IDAHO MODERN MEDICINE - PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:208-648-4789
Mailing Address - Street 1:1000 POCATELLO CREEK RD STE E10
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2953
Mailing Address - Country:US
Mailing Address - Phone:208-648-4789
Mailing Address - Fax:208-648-4790
Practice Address - Street 1:1000 POCATELLO CREEK RD STE E10
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2953
Practice Address - Country:US
Practice Address - Phone:208-317-5371
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-31
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty