Healthcare Provider Details

I. General information

NPI: 1285827253
Provider Name (Legal Business Name): IDAHO GYN/ONCOLOGY SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2007
Last Update Date: 03/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E IDAHO ST
BOISE ID
83712-6223
US

IV. Provider business mailing address

100 E IDAHO ST
BOISE ID
83712-6223
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-4171
  • Fax: 208-381-4172
Mailing address:
  • Phone: 208-381-4171
  • Fax: 208-381-4172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: IONA DYE
Title or Position: BILLING MANAGER
Credential: MD
Phone: 208-381-4171