Provider Demographics
NPI:1487151882
Name:PAGE FAMILY MEDICINE
Entity type:Organization
Organization Name:PAGE FAMILY MEDICINE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:B
Authorized Official - Last Name:HAYMORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-312-2242
Mailing Address - Street 1:260 FALLS AVE STE C
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3370
Mailing Address - Country:US
Mailing Address - Phone:208-736-7422
Mailing Address - Fax:708-736-8905
Practice Address - Street 1:1252 BENNETT AVE
Practice Address - Street 2:SUITE B
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318
Practice Address - Country:US
Practice Address - Phone:208-617-0656
Practice Address - Fax:208-647-0659
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHYSICIANS IMMEDIATE CARE OF TWIN FALLS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-04-11
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-4391207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1487151882Medicaid