Provider Demographics
NPI:1114141090
Name:PHYSICIANS IMMEDIATE CARE OF TWIN FALLS PA
Entity type:Organization
Organization Name:PHYSICIANS IMMEDIATE CARE OF TWIN FALLS PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLES
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:208-736-7422
Mailing Address - Street 1:243 CHENEY DR W STE 200
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3721
Mailing Address - Country:US
Mailing Address - Phone:208-736-7422
Mailing Address - Fax:208-736-8905
Practice Address - Street 1:243 CHENEY DR W STE 200
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3721
Practice Address - Country:US
Practice Address - Phone:208-736-7422
Practice Address - Fax:208-736-8905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1374581Medicare PIN