Provider Demographics
NPI:1982711578
Name:BOISE PODIATRY CLINIC, P. A.
Entity Type:Organization
Organization Name:BOISE PODIATRY CLINIC, P. A.
Other - Org Name:PODIATRY CENTER OF IDAHO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:J
Authorized Official - Last Name:MILLWARD
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:208-938-4670
Mailing Address - Street 1:6051 N EAGLE RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713
Mailing Address - Country:US
Mailing Address - Phone:208-938-4670
Mailing Address - Fax:208-938-4675
Practice Address - Street 1:6051 N EAGLE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713
Practice Address - Country:US
Practice Address - Phone:208-938-4670
Practice Address - Fax:208-938-4675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0779300001Medicare NSC
ID1350843Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER