Healthcare Provider Details

I. General information

NPI: 1881605590
Provider Name (Legal Business Name): MARK EDWARD BARADZIEJ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W FORT ST
BOISE ID
83702-4501
US

IV. Provider business mailing address

1735 ROANOKE DR
BOISE ID
83712-7524
US

V. Phone/Fax

Practice location:
  • Phone: 208-422-1136
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberM6801
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: