Provider Demographics
NPI:1902937196
Name:PAYETTE LAKES MEDICAL CLINIC, PA
Entity Type:Organization
Organization Name:PAYETTE LAKES MEDICAL CLINIC, PA
Other - Org Name:DONNELLY MEDICAL CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:VP - PHYSICIAN SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:R
Authorized Official - Last Name:BRUNS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-634-4061
Mailing Address - Street 1:PO BOX 1047
Mailing Address - Street 2:
Mailing Address - City:MCCALL
Mailing Address - State:ID
Mailing Address - Zip Code:83638-1047
Mailing Address - Country:US
Mailing Address - Phone:208-325-4455
Mailing Address - Fax:208-325-4466
Practice Address - Street 1:454 ROSEBURY ROAD
Practice Address - Street 2:SUITE 103
Practice Address - City:DONNELLY
Practice Address - State:ID
Practice Address - Zip Code:83615
Practice Address - Country:US
Practice Address - Phone:208-325-4455
Practice Address - Fax:208-325-4466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8N006OtherBC
ID000010160243OtherBS
ID000010160243OtherBS