Provider Demographics
NPI:1780867457
Name:SOUTHEAST IDAHO GASTROENTEROLOGY, PLLC
Entity type:Organization
Organization Name:SOUTHEAST IDAHO GASTROENTEROLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:FERREL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-232-6616
Mailing Address - Street 1:1151 HOSPITAL WAY STE A
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5091
Mailing Address - Country:US
Mailing Address - Phone:208-232-6616
Mailing Address - Fax:208-232-6618
Practice Address - Street 1:1151 HOSPITAL WAY STE A
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5091
Practice Address - Country:US
Practice Address - Phone:208-232-6616
Practice Address - Fax:208-232-6618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-17
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-629363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806196200Medicaid