Provider Demographics
NPI:1669405791
Name:THAYNE, ANDREW (MD)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:THAYNE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1951 BENCH RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2073
Mailing Address - Country:US
Mailing Address - Phone:208-238-1000
Mailing Address - Fax:208-238-0009
Practice Address - Street 1:1951 BENCH RD
Practice Address - Street 2:SUITE B
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2073
Practice Address - Country:US
Practice Address - Phone:208-238-1000
Practice Address - Fax:208-238-0009
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM9047207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP00108846OtherRAILROAD MEDICARE PTAN
ID806857400Medicaid
ID806857400Medicaid