Provider Demographics
NPI:1649345661
Name:IDAHO URGENT CARE
Entity type:Organization
Organization Name:IDAHO URGENT CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CANDACE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BUNNAGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-542-9111
Mailing Address - Street 1:740 S WOODRUFF AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-5285
Mailing Address - Country:US
Mailing Address - Phone:208-542-9111
Mailing Address - Fax:208-542-9114
Practice Address - Street 1:740 S WOODRUFF AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-5285
Practice Address - Country:US
Practice Address - Phone:208-542-9111
Practice Address - Fax:208-542-9114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8F280OtherBLUE CROSS GROUP
ID1371417Medicare ID - Type Unspecified