Provider Demographics
NPI:1982738662
Name:SOUTHEASTERN IDAHO MEDICAL CLINICS
Entity Type:Organization
Organization Name:SOUTHEASTERN IDAHO MEDICAL CLINICS
Other - Org Name:MALAD VALLEY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:208-766-2267
Mailing Address - Street 1:2750 S 4100 W
Mailing Address - Street 2:
Mailing Address - City:MALAD CITY
Mailing Address - State:ID
Mailing Address - Zip Code:83252-6542
Mailing Address - Country:US
Mailing Address - Phone:208-766-4118
Mailing Address - Fax:208-766-2342
Practice Address - Street 1:230 W 200 N
Practice Address - Street 2:
Practice Address - City:MALAD CITY
Practice Address - State:ID
Practice Address - Zip Code:83252-1109
Practice Address - Country:US
Practice Address - Phone:208-766-2267
Practice Address - Fax:208-766-2342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID0-41207Q00000X, 261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
D33608Medicare UPIN
TN1300530Medicare ID - Type Unspecified
TN133817Medicare ID - Type Unspecified