Healthcare Provider Details

I. General information

NPI: 1831326289
Provider Name (Legal Business Name): GERALD L KNOUF MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2009
Last Update Date: 12/08/2021
Certification Date: 12/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 W BURNSIDE AVE STE C
CHUBBUCK ID
83202-2411
US

IV. Provider business mailing address

190 W BURNSIDE AVE STE C
CHUBBUCK ID
83202
US

V. Phone/Fax

Practice location:
  • Phone: 208-023-8040
  • Fax: 208-238-0401
Mailing address:
  • Phone: 208-023-8040
  • Fax: 208-238-0401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. GERALD L KNOUF
Title or Position: OWNER
Credential: MD
Phone: 208-238-0400