Provider Demographics
NPI:1912238544
Name:ROGER H. TALL M.D. P.A.
Entity Type:Organization
Organization Name:ROGER H. TALL M.D. P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:H
Authorized Official - Last Name:TALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-529-0633
Mailing Address - Street 1:2001 S WOODRUFF
Mailing Address - Street 2:SUITE 8
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404
Mailing Address - Country:US
Mailing Address - Phone:208-529-0633
Mailing Address - Fax:208-529-1948
Practice Address - Street 1:2001 S WOODRUFF
Practice Address - Street 2:SUITE 8
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404
Practice Address - Country:US
Practice Address - Phone:208-529-0633
Practice Address - Fax:208-529-1948
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-21
Last Update Date:2010-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM4222174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty