Healthcare Provider Details

I. General information

NPI: 1376362038
Provider Name (Legal Business Name): PEDIATRIC CARDIOLOGY OF IDAHO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2024
Last Update Date: 10/08/2024
Certification Date: 10/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 N LIBERTY ST STE 206
BOISE ID
83704-8729
US

IV. Provider business mailing address

2225 E SOLITUDE CT
BOISE ID
83712-7576
US

V. Phone/Fax

Practice location:
  • Phone: 208-453-9962
  • Fax: 208-453-9963
Mailing address:
  • Phone: 208-453-9962
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: WHITNEY BAIRD
Title or Position: OFFICE MANAGER
Credential:
Phone: 208-453-9962