Provider Demographics
NPI:1902891518
Name:EMRY, GEOFFREY THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:THOMAS
Last Name:EMRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 W IRONWOOD DR STE 101
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2464
Mailing Address - Country:US
Mailing Address - Phone:208-667-4557
Mailing Address - Fax:208-765-2887
Practice Address - Street 1:920 W IRONWOOD DR STE 101
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2464
Practice Address - Country:US
Practice Address - Phone:208-667-4557
Practice Address - Fax:208-765-2887
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM8556207Q00000X
WAMD00041052207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806393700Medicaid
ID806393700Medicaid
H73994Medicare UPIN