Provider Demographics
NPI:1902143134
Name:ENNIS ENDOCRINOLOGY, PLLC
Entity Type:Organization
Organization Name:ENNIS ENDOCRINOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:FRANK
Authorized Official - Last Name:ENNIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-994-8180
Mailing Address - Street 1:2498 W TIMBER DR
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-4665
Mailing Address - Country:US
Mailing Address - Phone:208-994-8180
Mailing Address - Fax:
Practice Address - Street 1:2450 E GALA ST STE 100
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-4805
Practice Address - Country:US
Practice Address - Phone:208-994-8180
Practice Address - Fax:208-908-4542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-08
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-11309207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty