Healthcare Provider Details

I. General information

NPI: 1265486625
Provider Name (Legal Business Name): MURALI N BATHINA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 09/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 E ELM STREET STE 350
CALDWELL ID
83605
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-454-6363
  • Fax: 208-454-3512
Mailing address:
  • Phone: 208-322-1680
  • Fax: 208-322-1695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberM6347
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: