Healthcare Provider Details

I. General information

NPI: 1588629406
Provider Name (Legal Business Name): RUSSELL M KOCEMBA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 01/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 N SAWGRASS WAY
BOISE ID
83704-4493
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-375-0862
  • Fax: 208-375-2658
Mailing address:
  • Phone: 208-375-0862
  • Fax: 208-375-2658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM7077
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: