Provider Demographics
NPI:1063551174
Name:IDAHO CENTER FOR REPRODUCTIVE MEDICINE PC
Entity type:Organization
Organization Name:IDAHO CENTER FOR REPRODUCTIVE MEDICINE PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUS ADMIN
Authorized Official - Prefix:MRS
Authorized Official - First Name:GENIE
Authorized Official - Middle Name:T
Authorized Official - Last Name:ANDREWS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-342-5900
Mailing Address - Street 1:111 MAIN ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-7307
Mailing Address - Country:US
Mailing Address - Phone:208-342-5900
Mailing Address - Fax:208-342-2088
Practice Address - Street 1:111 MAIN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-7307
Practice Address - Country:US
Practice Address - Phone:208-342-5900
Practice Address - Fax:208-342-2088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM8614207VE0102X
IDM7577207VE0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive EndocrinologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8G189OtherBLUE CROSS CLINIC
ID513COOtherBLUE CROSS DR FOULK
ID51292OtherBLUE CROSS DR SLATER
F73587Medicare UPIN
ID513COOtherBLUE CROSS DR FOULK