Provider Demographics
NPI:1104220797
Name:BOISE SKIN CLINIC PLLC
Entity type:Organization
Organization Name:BOISE SKIN CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARNIE
Authorized Official - Middle Name:R
Authorized Official - Last Name:RIRIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-258-2078
Mailing Address - Street 1:1636 S HADLEY AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-2684
Mailing Address - Country:US
Mailing Address - Phone:208-209-7898
Mailing Address - Fax:208-258-2079
Practice Address - Street 1:1636 S HADLEY AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-2684
Practice Address - Country:US
Practice Address - Phone:208-209-7898
Practice Address - Fax:208-258-2079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-10
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-9342207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1134170855Medicaid