Provider Demographics
NPI:1427523968
Name:Q17 HEALTH PARTNERS LLC
Entity type:Organization
Organization Name:Q17 HEALTH PARTNERS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:H
Authorized Official - Last Name:GRIFFITHS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-433-1736
Mailing Address - Street 1:100 EAST IDAHO STREET #317
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712
Mailing Address - Country:US
Mailing Address - Phone:208-433-1736
Mailing Address - Fax:208-433-1738
Practice Address - Street 1:100 EAST IDAHO STREET #317
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712
Practice Address - Country:US
Practice Address - Phone:208-433-1736
Practice Address - Fax:208-433-1738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-11
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805132700Medicaid