Provider Demographics
NPI:1720423429
Name:IDAHO NEUROLOGY PLLC
Entity Type:Organization
Organization Name:IDAHO NEUROLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:SWANSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:406-274-2295
Mailing Address - Street 1:2825 FORT MISSOULA RD STE 121
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-7403
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:901 N CURTIS RD
Practice Address - Street 2:SUITE 101
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1338
Practice Address - Country:US
Practice Address - Phone:208-608-5825
Practice Address - Fax:208-287-3690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-08
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM118962084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty