Provider Demographics
NPI:1588724744
Name:UPPER VALLEY PEDIATRICS
Entity type:Organization
Organization Name:UPPER VALLEY PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GENE
Authorized Official - Middle Name:PRESTON
Authorized Official - Last Name:GATES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-356-0234
Mailing Address - Street 1:36 PROFESSIONAL PLAZA
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440
Mailing Address - Country:US
Mailing Address - Phone:208-356-0234
Mailing Address - Fax:208-656-8440
Practice Address - Street 1:36 PROFESSIONAL PLAZA
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440
Practice Address - Country:US
Practice Address - Phone:208-356-0234
Practice Address - Fax:208-656-8440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty