Healthcare Provider Details

I. General information

NPI: 1417314543
Provider Name (Legal Business Name): IDAHO EMERGENCY MEDICAL GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2016
Last Update Date: 03/04/2020
Certification Date: 03/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 ARLINGTON AVE
CALDWELL ID
83605-4802
US

IV. Provider business mailing address

5000 HOPYARD RD SUITE 100
PLEASANTON CA
94588-3348
US

V. Phone/Fax

Practice location:
  • Phone: 208-459-4641
  • Fax: 208-455-3717
Mailing address:
  • Phone: 925-924-1600
  • Fax: 925-924-0506

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: SHARON HARDY
Title or Position: PE DIRECTOR
Credential:
Phone: 925-251-6901