MEDICARE: GEM FAMILY PRACTICE, INC

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	261QR1300X	Rural Health Clinic/Center	PA 281	ID

General Provider Information

NPI Number	:	1205052198
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GEM FAMILY PRACTICE, INC

Provider Business Mailing Address
First Line	:	1108 S WASHINGTON AVE
Second Line	:
City	:	EMMETT
State	:	ID
Zip	:	83617-3535
Country	:	US
Telephone Number	:	208-365-3455
Fax Number	:	208-365-3422

Provider Business Practice Location Address
First Line	:	1108 S WASHINGTON AVE
Second Line	:
City	:	EMMETT
State	:	ID
Zip	:	83617-3535
Country	:	US
Telephone Number	:	208-365-3455
Fax Number	:	208-365-3422

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JENNICE M CORDOVA
Credential	:	MPA-C
Telephone Number	:	208-365-3455

Provider Enumeration Date	:	04/18/2007
Last Update Date	:	08/22/2020

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