Provider Demographics
NPI:1982779815
Name:MICHAEL D LAHEY MD LLC
Entity Type:Organization
Organization Name:MICHAEL D LAHEY MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:DUANE
Authorized Official - Last Name:LAHEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-938-4080
Mailing Address - Street 1:323 E RIVERSIDE DRIVE
Mailing Address - Street 2:SUITE 234
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616
Mailing Address - Country:US
Mailing Address - Phone:208-938-4080
Mailing Address - Fax:208-938-8922
Practice Address - Street 1:323 E RIVERSIDE DRIVE
Practice Address - Street 2:SUITE 234
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616
Practice Address - Country:US
Practice Address - Phone:208-938-4080
Practice Address - Fax:208-938-8922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-24
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5743174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002913000Medicaid
ID002913000Medicaid