Healthcare Provider Details

I. General information

NPI: 1912040270
Provider Name (Legal Business Name): GEM STATE DERMATOLOGY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 12/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

388 E. PARKCENTER BLVD.
BOISE ID
83706
US

IV. Provider business mailing address

PO BOX 1603
BOISE ID
83702-1603
US

V. Phone/Fax

Practice location:
  • Phone: 208-424-9101
  • Fax: 208-424-5072
Mailing address:
  • Phone: 208-424-9101
  • Fax: 208-424-5072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberM7247
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberM7247
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA377
License Number StateID

VIII. Authorized Official

Name: MS. MICHELLE MORGAN
Title or Position: PRACTICE MANAGER
Credential:
Phone: 208-424-9101