Healthcare Provider Details

I. General information

NPI: 1982632550
Provider Name (Legal Business Name): FAMILY PRACTICE RESIDENCY OF IDAHO, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 01/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 N RAYMOND ST
BOISE ID
83704-9251
US

IV. Provider business mailing address

777 N RAYMOND ST
BOISE ID
83704-9251
US

V. Phone/Fax

Practice location:
  • Phone: 208-367-6030
  • Fax: 208-367-6123
Mailing address:
  • Phone: 208-367-6030
  • Fax: 208-367-6123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: TED EPPERLY
Title or Position: CHAIRMAN AND PROGRAM DIRECTOR
Credential: M.D.
Phone: 208-367-6042