Provider Demographics
NPI:1124115944
Name:TONY C ROISUM MD PA
Entity type:Organization
Organization Name:TONY C ROISUM MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER / PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TONY
Authorized Official - Middle Name:C
Authorized Official - Last Name:ROISUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-524-3416
Mailing Address - Street 1:3360 WASHINGTON PKWY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8333
Mailing Address - Country:US
Mailing Address - Phone:208-524-3416
Mailing Address - Fax:208-524-3138
Practice Address - Street 1:3360 WASHINGTON PKWY
Practice Address - Street 2:SUITE 1
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8333
Practice Address - Country:US
Practice Address - Phone:208-524-3416
Practice Address - Fax:208-524-3138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2016-05-20
Deactivation Date:2007-07-24
Deactivation Code:
Reactivation Date:2008-12-09
Provider Licenses
StateLicense IDTaxonomies
IDM7389207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010004286OtherBLUE SHIELD
B5824OtherBLUE CROSS
IDDJ475OtherBLUE CROSS
WY119166700Medicaid
ID185461600OtherUS DEPT OF LABOR
UT502862456001Medicaid
23397OtherBLUE SHIELD
ID805076700Medicaid
IDDJ475OtherBLUE CROSS
23397OtherBLUE SHIELD
ID185461600OtherUS DEPT OF LABOR
ID1138391Medicare ID - Type Unspecified