Healthcare Provider Details

I. General information

NPI: 1104878610
Provider Name (Legal Business Name): MICHAEL A KAYLOR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 10/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 S EAGLE RD
EAGLE ID
83616-6067
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712
US

V. Phone/Fax

Practice location:
  • Phone: 208-939-8200
  • Fax: 208-939-8222
Mailing address:
  • Phone: 208-375-4955
  • Fax: 208-375-5568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM9661
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: