Healthcare Provider Details

I. General information

NPI: 1508043001
Provider Name (Legal Business Name): MARK ROBERT URBAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2008
Last Update Date: 03/09/2021
Certification Date: 03/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 E BANNOCK ST
BOISE ID
83712-6241
US

IV. Provider business mailing address

4195 N BODENHEIMER ST
BOISE ID
83703-4201
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-1000
  • Fax:
Mailing address:
  • Phone: 208-629-2146
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number80808
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number80808
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: