Provider Demographics
NPI:1740493832
Name:SANDPOINT FAMILY MEDICINE PA
Entity type:Organization
Organization Name:SANDPOINT FAMILY MEDICINE PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:RUST
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:208-263-5109
Mailing Address - Street 1:302 S 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-1258
Mailing Address - Country:US
Mailing Address - Phone:208-263-5109
Mailing Address - Fax:208-263-5112
Practice Address - Street 1:302 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-1258
Practice Address - Country:US
Practice Address - Phone:208-263-5109
Practice Address - Fax:208-263-5112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1374444Medicare ID - Type Unspecified