Provider Demographics
NPI:1356759781
Name:IDAHO JOINT AND SPINE PC
Entity type:Organization
Organization Name:IDAHO JOINT AND SPINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:WHITAKER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:208-322-5922
Mailing Address - Street 1:9510 W FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8103
Mailing Address - Country:US
Mailing Address - Phone:208-322-5922
Mailing Address - Fax:844-502-7766
Practice Address - Street 1:9510 W FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8103
Practice Address - Country:US
Practice Address - Phone:208-322-5922
Practice Address - Fax:844-502-7766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-29
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-0794204D00000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1356759781-001Medicaid
ID20005643Medicare PIN