Provider Demographics
NPI:1831326289
Name:GERALD L KNOUF MD PA
Entity type:Organization
Organization Name:GERALD L KNOUF MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:L
Authorized Official - Last Name:KNOUF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-238-0400
Mailing Address - Street 1:190 W BURNSIDE AVE
Mailing Address - Street 2:STE C
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202
Mailing Address - Country:US
Mailing Address - Phone:208-023-8040
Mailing Address - Fax:208-238-0401
Practice Address - Street 1:190 W BURNSIDE AVE
Practice Address - Street 2:STE C
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-2411
Practice Address - Country:US
Practice Address - Phone:208-023-8040
Practice Address - Fax:208-238-0401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-12
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID11043901OtherMEDICARE PTAN