Healthcare Provider Details

I. General information

NPI: 1164476131
Provider Name (Legal Business Name): KAREN M REDWINE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 09/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 E JEFFERSON ST
BOISE ID
83712-6273
US

IV. Provider business mailing address

305 E JEFFERSON ST
BOISE ID
83712-6273
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-7336
  • Fax:
Mailing address:
  • Phone: 208-381-7336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberM0173
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License NumberE-5176
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License NumberM0173
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License NumberM-13200
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: