Provider Demographics
NPI:1487693032
Name:BOISE OBSTETRIC & GYNECOLOGIC ASSOCIATES PA
Entity type:Organization
Organization Name:BOISE OBSTETRIC & GYNECOLOGIC ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:R
Authorized Official - Last Name:GLEASON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-375-8100
Mailing Address - Street 1:5966 CURTISIAN AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704
Mailing Address - Country:US
Mailing Address - Phone:208-375-8100
Mailing Address - Fax:208-373-2643
Practice Address - Street 1:5966 CURTISIAN AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704
Practice Address - Country:US
Practice Address - Phone:208-375-8100
Practice Address - Fax:208-373-2643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-06
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID290426OtherBLUE SHIELD
ID29381OtherBLUE SHIELD
ID8E936OtherBLUE CROSS
ID89300OtherBLUE CROSS
ID808037700Medicaid
ID29381OtherBLUE SHIELD