MEDICARE: DOCTORS CLINIC OF ELMORE COUNTY PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA-265	ID
2	207Q00000X	Family Medicine Physician	O-91	ID

General Provider Information

NPI Number	:	1063578664
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOCTORS CLINIC OF ELMORE COUNTY PLLC

Provider Business Mailing Address
First Line	:	2000 AMERICAN LEGION BLVD
Second Line	:
City	:	MOUNTAIN HOME
State	:	ID
Zip	:	83647-3138
Country	:	US
Telephone Number	:	208-587-1500
Fax Number	:	208-587-3180

Provider Business Practice Location Address
First Line	:	2000 AMERICAN LEGION BLVD
Second Line	:
City	:	MOUNTAIN HOME
State	:	ID
Zip	:	83647-3138
Country	:	US
Telephone Number	:	208-587-1500
Fax Number	:	208-587-3180

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DR. LAYNE D ROBERTS
Credential	:	D.O.
Telephone Number	:	208-587-1500

Provider Enumeration Date	:	12/28/2006
Last Update Date	:	02/25/2008

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