Provider Demographics
NPI:1295272490
Name:THERAN ADAMSON, MD PLLC
Entity type:Organization
Organization Name:THERAN ADAMSON, MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THERAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ADAMSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-765-5922
Mailing Address - Street 1:914 W IRONWOOD DR
Mailing Address - Street 2:STE 102
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-4927
Mailing Address - Country:US
Mailing Address - Phone:208-765-5922
Mailing Address - Fax:
Practice Address - Street 1:914 W IRONWOOD DR
Practice Address - Street 2:STE 102
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4927
Practice Address - Country:US
Practice Address - Phone:208-765-5922
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-25
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-12662207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDM-12662OtherID LICENSE