Provider Demographics
NPI:1205634607
Name:WEST IDAHO IMEDCARE
Entity type:Organization
Organization Name:WEST IDAHO IMEDCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHANAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HOGG
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:808-294-7862
Mailing Address - Street 1:PO BOX 188
Mailing Address - Street 2:
Mailing Address - City:GREENLEAF
Mailing Address - State:ID
Mailing Address - Zip Code:83626-0188
Mailing Address - Country:US
Mailing Address - Phone:208-261-2030
Mailing Address - Fax:
Practice Address - Street 1:22872 AURA VISTA WAY
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83607-5593
Practice Address - Country:US
Practice Address - Phone:808-294-7862
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-04
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty