Provider Demographics
NPI:1336214618
Name:IDAHO STATE UNIVERSITY HEALTH CENTER
Entity Type:Organization
Organization Name:IDAHO STATE UNIVERSITY HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:M
Authorized Official - Last Name:SOLBRIG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-282-2330
Mailing Address - Street 1:921 S 8TH AVE STOP 8311
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83209-0002
Mailing Address - Country:US
Mailing Address - Phone:208-282-2330
Mailing Address - Fax:208-282-4036
Practice Address - Street 1:990 CESAR CHAVEZ AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83209-0001
Practice Address - Country:US
Practice Address - Phone:208-282-2330
Practice Address - Fax:208-282-4036
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IDAHO STATE UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-21
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health