Healthcare Provider Details

I. General information

NPI: 1477546208
Provider Name (Legal Business Name): MARK S MCCONNELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 03/23/2022
Certification Date: 03/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W. FORT ST. MAIL CODE 111
BOISE ID
83702-6241
US

IV. Provider business mailing address

500 W. FORT ST. MAIL CODE 111
BOISE ID
83702-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-422-1325
  • Fax: 208-422-1319
Mailing address:
  • Phone: 208-422-1325
  • Fax: 208-422-1319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberM9326
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberM9326
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: