Provider Demographics
NPI:1295140648
Name:HODGES FAMILY MEDICINE, PLLC
Entity type:Organization
Organization Name:HODGES FAMILY MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:HODGES
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:208-854-9534
Mailing Address - Street 1:1350 S FIVE MILE RD
Mailing Address - Street 2:#191220
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-0020
Mailing Address - Country:US
Mailing Address - Phone:208-854-9534
Mailing Address - Fax:
Practice Address - Street 1:2947 E MAGIC VIEW DR
Practice Address - Street 2:SUITE #1
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-3561
Practice Address - Country:US
Practice Address - Phone:208-854-9534
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-24
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-109207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty