Provider Demographics
NPI:1992728976
Name:OWYHEE MEDICAL CLINIC PA
Entity type:Organization
Organization Name:OWYHEE MEDICAL CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:F
Authorized Official - Last Name:NOAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-337-3233
Mailing Address - Street 1:PO BOX 16820
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83715-6820
Mailing Address - Country:US
Mailing Address - Phone:208-337-3233
Mailing Address - Fax:
Practice Address - Street 1:106 WEST IDAHO AVENUE
Practice Address - Street 2:
Practice Address - City:HOMEDALE
Practice Address - State:ID
Practice Address - Zip Code:83628
Practice Address - Country:US
Practice Address - Phone:208-337-3233
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1374386Medicare PIN