Provider Demographics
NPI:1952335929
Name:PIONEER FAMILY MEDICINE PLLC
Entity type:Organization
Organization Name:PIONEER FAMILY MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:LUDWIG
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:208-938-3663
Mailing Address - Street 1:4740 N. PENNGROVE WAY
Mailing Address - Street 2:STE. 100
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646
Mailing Address - Country:US
Mailing Address - Phone:208-938-3663
Mailing Address - Fax:208-938-3664
Practice Address - Street 1:4740 N. PENNGROVE WAY
Practice Address - Street 2:STE. 100
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646
Practice Address - Country:US
Practice Address - Phone:208-938-3663
Practice Address - Fax:208-938-3664
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-253207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806456700Medicaid
IDH26149Medicare UPIN