Provider Demographics
NPI:1467963496
Name:KURT E KRACAW MD LLC
Entity type:Organization
Organization Name:KURT E KRACAW MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KURT
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:KRACAW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:775-772-4208
Mailing Address - Street 1:PO BOX 3208
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-3208
Mailing Address - Country:US
Mailing Address - Phone:208-523-4906
Mailing Address - Fax:208-523-2025
Practice Address - Street 1:426 FARNSWORTH WAY STE 1
Practice Address - Street 2:
Practice Address - City:RIGBY
Practice Address - State:ID
Practice Address - Zip Code:83442-4713
Practice Address - Country:US
Practice Address - Phone:208-745-9411
Practice Address - Fax:208-745-9910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-17
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-13115207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1285723460OtherTYPE 1 NPI