Healthcare Provider Details

I. General information

NPI: 1073080313
Provider Name (Legal Business Name): BRIDGEWELL MEDICAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2018
Last Update Date: 07/29/2023
Certification Date: 07/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 W MAIN ST SUITE 1460
BOISE ID
83702-9030
US

IV. Provider business mailing address

PO BOX 6795
BOISE ID
83707-0795
US

V. Phone/Fax

Practice location:
  • Phone: 208-505-1179
  • Fax:
Mailing address:
  • Phone: 208-505-1179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DAWN SCHOTT
Title or Position: PRESIDENT
Credential:
Phone: 208-505-1179