Provider Demographics
NPI:1154356624
Name:IDAHO SPORTS MEDICINE INSTITUTE, PA
Entity type:Organization
Organization Name:IDAHO SPORTS MEDICINE INSTITUTE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:R
Authorized Official - Last Name:MILLIER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-336-8250
Mailing Address - Street 1:1188 UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-3009
Mailing Address - Country:US
Mailing Address - Phone:208-336-8250
Mailing Address - Fax:208-345-9514
Practice Address - Street 1:1188 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-3009
Practice Address - Country:US
Practice Address - Phone:208-336-8250
Practice Address - Fax:208-345-9514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
N/A FOR GROUP204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805993900Medicaid
IDREGENCE BLUE SHIELDOtherGROUP # 29145
ID8628-0OtherBLUE CROSS OF IDAHO GROUP
ID805993900Medicaid