Provider Demographics
NPI:1508086018
Name:IDAHO FALLS PHYSICAL MEDICINE & REHABILITATION
Entity Type:Organization
Organization Name:IDAHO FALLS PHYSICAL MEDICINE & REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:C
Authorized Official - Last Name:SIMON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-535-4420
Mailing Address - Street 1:2860 CHANNING WAY
Mailing Address - Street 2:SUITE 213
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7531
Mailing Address - Country:US
Mailing Address - Phone:208-535-4420
Mailing Address - Fax:208-535-4427
Practice Address - Street 1:2860 CHANNING WAY
Practice Address - Street 2:SUITE 213
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7531
Practice Address - Country:US
Practice Address - Phone:208-535-4420
Practice Address - Fax:208-535-4427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6825208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDF79761Medicare UPIN
ID1133268Medicare ID - Type Unspecified