Provider Demographics
NPI:1588861405
Name:PODIATRY SERVICES OF IDAHO, PLLC
Entity type:Organization
Organization Name:PODIATRY SERVICES OF IDAHO, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CAMILLE
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:208-402-6587
Mailing Address - Street 1:1105 E USTICK RD
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-6306
Mailing Address - Country:US
Mailing Address - Phone:208-402-6587
Mailing Address - Fax:208-402-6578
Practice Address - Street 1:229 E LOGAN ST
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4835
Practice Address - Country:US
Practice Address - Phone:208-402-6587
Practice Address - Fax:084-026-5782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-03
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00359213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR023111Medicaid
ORP00251554OtherRAILROAD MEDICARE
ORDD5083OtherRAILROAD MEDICARE GROUP NUMBER
OR4540570001OtherMEDICARE DMERC
ID807150700Medicaid
ORP00251554OtherRAILROAD MEDICARE
ORDD5083OtherRAILROAD MEDICARE GROUP NUMBER
OR023111Medicaid
OR6085330001Medicare NSC
OR4540570001OtherMEDICARE DMERC