Provider Demographics
NPI:1801292115
Name:IDAHO STATE UNIVERSITY
Entity type:Organization
Organization Name:IDAHO STATE UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:HEAD ATHLETIC TRAINER
Authorized Official - Prefix:
Authorized Official - First Name:JODI
Authorized Official - Middle Name:
Authorized Official - Last Name:WOTOWEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-282-3408
Mailing Address - Street 1:5050 SPRING VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75244-3995
Mailing Address - Country:US
Mailing Address - Phone:800-555-9073
Mailing Address - Fax:972-367-3452
Practice Address - Street 1:921 S 8TH AVE STOP 8173
Practice Address - Street 2:SPORTS AND ORTHOPAEDIC CENTER
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83209-8173
Practice Address - Country:US
Practice Address - Phone:208-282-3408
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-13
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty