Provider Demographics
NPI:1912110164
Name:IDAHO STATE UNIVERSITY
Entity Type:Organization
Organization Name:IDAHO STATE UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:FREEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:BHSA
Authorized Official - Phone:208-331-0182
Mailing Address - Street 1:2033 E SUMMERSWEET DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83716-6695
Mailing Address - Country:US
Mailing Address - Phone:208-331-0182
Mailing Address - Fax:208-331-0184
Practice Address - Street 1:2033 E SUMMERSWEET DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83716-6695
Practice Address - Country:US
Practice Address - Phone:208-331-0182
Practice Address - Fax:208-331-0184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-1819122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807200600Medicaid