Provider Demographics
NPI:1932392933
Name:TIMBERLAKE FAMILY MEDICINE
Entity Type:Organization
Organization Name:TIMBERLAKE FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:SUNDQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:208-683-0800
Mailing Address - Street 1:PO BOX 775
Mailing Address - Street 2:
Mailing Address - City:ATHOL
Mailing Address - State:ID
Mailing Address - Zip Code:83801-0775
Mailing Address - Country:US
Mailing Address - Phone:208-683-0800
Mailing Address - Fax:208-683-0900
Practice Address - Street 1:6101 E HIGHWAY 54 STE A
Practice Address - Street 2:
Practice Address - City:ATHOL
Practice Address - State:ID
Practice Address - Zip Code:83801-8255
Practice Address - Country:US
Practice Address - Phone:208-683-0800
Practice Address - Fax:208-683-0900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-22
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA303261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAD92OtherBLUE CROSS
000010158675OtherREGENCE
P23313Medicare UPIN
PAD92OtherBLUE CROSS