Provider Demographics
NPI:1255621835
Name:TAMARACK EAGLE MEDICAL
Entity type:Organization
Organization Name:TAMARACK EAGLE MEDICAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROURKE
Authorized Official - Middle Name:
Authorized Official - Last Name:YEAKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-724-7420
Mailing Address - Street 1:5701 WILLOW CREEK RD
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-2025
Mailing Address - Country:US
Mailing Address - Phone:208-724-7420
Mailing Address - Fax:
Practice Address - Street 1:311 VILLAGE DR
Practice Address - Street 2:
Practice Address - City:TAMARACK
Practice Address - State:ID
Practice Address - Zip Code:83615-5014
Practice Address - Country:US
Practice Address - Phone:208-724-7420
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-15
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
122300000X
IDM8190208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty