Provider Demographics
NPI:1356942437
Name:STODDARD & BINGHAM MEDICAL OF REXBURG PLLC
Entity type:Organization
Organization Name:STODDARD & BINGHAM MEDICAL OF REXBURG PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RALENE
Authorized Official - Middle Name:
Authorized Official - Last Name:REDFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:208-238-7546
Mailing Address - Street 1:147 W CHUBBUCK RD
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-2314
Mailing Address - Country:US
Mailing Address - Phone:208-238-7546
Mailing Address - Fax:208-238-7546
Practice Address - Street 1:859 S YELLOWSTONE HWY STE 3302
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-6200
Practice Address - Country:US
Practice Address - Phone:208-656-2160
Practice Address - Fax:208-656-2161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty