Healthcare Provider Details

I. General information

NPI: 1063551174
Provider Name (Legal Business Name): IDAHO CENTER FOR REPRODUCTIVE MEDICINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 MAIN ST SUITE 100
BOISE ID
83702-7307
US

IV. Provider business mailing address

111 MAIN ST SUITE 100
BOISE ID
83702-7307
US

V. Phone/Fax

Practice location:
  • Phone: 208-342-5900
  • Fax: 208-342-2088
Mailing address:
  • Phone: 208-342-5900
  • Fax: 208-342-2088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License NumberM8614
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License NumberM7577
License Number StateID

VIII. Authorized Official

Name: MRS. GENIE T ANDREWS
Title or Position: BUS ADMIN
Credential:
Phone: 208-342-5900