Healthcare Provider Details

I. General information

NPI: 1346400744
Provider Name (Legal Business Name): LEE SELF MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2008
Last Update Date: 03/24/2023
Certification Date: 03/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 S JOHNS AVE STE B
EMMETT ID
83617-9410
US

IV. Provider business mailing address

23000 SWEET OLA HWY
OLA ID
83657-5027
US

V. Phone/Fax

Practice location:
  • Phone: 208-425-7507
  • Fax: 208-584-9341
Mailing address:
  • Phone: 208-425-7507
  • Fax: 208-584-9341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberM7844
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LEE SELF
Title or Position: PRESIDENT
Credential: MD
Phone: 208-425-7507