Healthcare Provider Details

I. General information

NPI: 1104932839
Provider Name (Legal Business Name): RUSSELL TURNER SNOW DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 09/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 WEST LOGAN STREET STE A
CALDWELL ID
83605
US

IV. Provider business mailing address

119 WEST LOGAN STREET STE A
CALDWELL ID
83605
US

V. Phone/Fax

Practice location:
  • Phone: 208-454-2050
  • Fax: 208-454-3554
Mailing address:
  • Phone: 208-454-2050
  • Fax: 208-454-3554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number0110
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: