Provider Demographics
NPI:1306984943
Name:RONALD S HIGGINBOTHAM, DO PA
Entity type:Organization
Organization Name:RONALD S HIGGINBOTHAM, DO PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:E
Authorized Official - Last Name:HUMMEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-376-2522
Mailing Address - Street 1:7685 W EMERALD ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9018
Mailing Address - Country:US
Mailing Address - Phone:208-376-2522
Mailing Address - Fax:208-375-5860
Practice Address - Street 1:7685 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9018
Practice Address - Country:US
Practice Address - Phone:208-376-2522
Practice Address - Fax:208-375-5860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-04
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-50207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty