Provider Demographics
NPI:1730272006
Name:MOUNTAIN STATES MEDICAL GROUP PA
Entity type:Organization
Organization Name:MOUNTAIN STATES MEDICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCHRYSTAL
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:208-378-2840
Mailing Address - Street 1:PO BOX 4236
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83711-4236
Mailing Address - Country:US
Mailing Address - Phone:208-378-2840
Mailing Address - Fax:208-323-9070
Practice Address - Street 1:4809 FAIRVIEW AVENUE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-2242
Practice Address - Country:US
Practice Address - Phone:208-378-2840
Practice Address - Fax:208-323-9070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-01
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010017966OtherRBSI
ID8C196OtherBLUE CROSS
ID000010017966OtherRBSI
ID4930450001Medicare NSC