Healthcare Provider Details

I. General information

NPI: 1134170855
Provider Name (Legal Business Name): MARNIE R RIRIE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 01/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1636 HADLEY AVE.
BOISE ID
83709
US

IV. Provider business mailing address

1636 S HADLEY AVE
BOISE ID
83709-2684
US

V. Phone/Fax

Practice location:
  • Phone: 208-258-2078
  • Fax: 208-258-2079
Mailing address:
  • Phone: 208-209-7898
  • Fax: 208-258-2079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberM-9342
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberM9342
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: