Provider Demographics
NPI:1780871467
Name:IDAHO PEDIATRIC GASTROENTEROLOGY PA
Entity type:Organization
Organization Name:IDAHO PEDIATRIC GASTROENTEROLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:R
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-381-7310
Mailing Address - Street 1:100 E IDAHO ST
Mailing Address - Street 2:SUITE 316
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6223
Mailing Address - Country:US
Mailing Address - Phone:208-381-7310
Mailing Address - Fax:
Practice Address - Street 1:100 E IDAHO ST
Practice Address - Street 2:SUITE 316
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6223
Practice Address - Country:US
Practice Address - Phone:208-381-7310
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-26
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7673174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty