Provider Demographics
NPI:1538238571
Name:IDAHO ORTHOPEDIC & SPORTS CLINIC PA
Entity type:Organization
Organization Name:IDAHO ORTHOPEDIC & SPORTS CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-234-1960
Mailing Address - Street 1:560 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4073
Mailing Address - Country:US
Mailing Address - Phone:208-234-1969
Mailing Address - Fax:208-233-5033
Practice Address - Street 1:560 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4073
Practice Address - Country:US
Practice Address - Phone:208-234-1969
Practice Address - Fax:208-233-5033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805136500Medicaid
ID1374081Medicare ID - Type Unspecified