Provider Demographics
NPI:1528263670
Name:SNAKE RIVER DERMATOLOGY, PA
Entity type:Organization
Organization Name:SNAKE RIVER DERMATOLOGY, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:BROCK
Authorized Official - Middle Name:ARBEN
Authorized Official - Last Name:ANDERSEN
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:208-452-5999
Mailing Address - Street 1:1611 N WHITLEY DR
Mailing Address - Street 2:SUITE #7
Mailing Address - City:FRUITLAND
Mailing Address - State:ID
Mailing Address - Zip Code:83619
Mailing Address - Country:US
Mailing Address - Phone:208-452-5999
Mailing Address - Fax:208-452-4499
Practice Address - Street 1:1611 N WHITLEY DR
Practice Address - Street 2:#7
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619
Practice Address - Country:US
Practice Address - Phone:208-452-5999
Practice Address - Fax:208-452-4499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-19
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM3809207N00000X
IDM-11462207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1376760Medicare ID - Type Unspecified