Provider Demographics
NPI:1205875275
Name:EMERGENCY MEDICINE OF IDAHO
Entity type:Organization
Organization Name:EMERGENCY MEDICINE OF IDAHO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:BISHOP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-615-8201
Mailing Address - Street 1:3080 E GENTRY WAY STE 210
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-3013
Mailing Address - Country:US
Mailing Address - Phone:208-615-8201
Mailing Address - Fax:208-779-2971
Practice Address - Street 1:3080 E GENTRY WAY STE 210
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-3013
Practice Address - Country:US
Practice Address - Phone:208-615-8201
Practice Address - Fax:208-779-2971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-05
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID207P00000X, 207PE0005X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010148698OtherREGENCE BLUE SHIELD IF ID
ID807026800Medicaid
ID8K743OtherBLUE CROSS OF IDAHO