Provider Demographics
NPI:1720692650
Name:KETCHUM FAMILY MEDICINE, PLLC
Entity Type:Organization
Organization Name:KETCHUM FAMILY MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:208-721-0676
Mailing Address - Street 1:PO BOX 6471
Mailing Address - Street 2:
Mailing Address - City:KETCHUM
Mailing Address - State:ID
Mailing Address - Zip Code:83340-6471
Mailing Address - Country:US
Mailing Address - Phone:208-622-3180
Mailing Address - Fax:
Practice Address - Street 1:431 WALNUT AVE N
Practice Address - Street 2:
Practice Address - City:KETCHUM
Practice Address - State:ID
Practice Address - Zip Code:83340
Practice Address - Country:US
Practice Address - Phone:208-622-3180
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-08
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty