Healthcare Provider Details

I. General information

NPI: 1700579703
Provider Name (Legal Business Name): BRIGHAM HARDY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2023
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 E LOCUST ST
EMMETT ID
83617-2715
US

IV. Provider business mailing address

1202 E LOCUST ST
EMMETT ID
83617-2715
US

V. Phone/Fax

Practice location:
  • Phone: 208-365-3561
  • Fax:
Mailing address:
  • Phone: 208-365-3561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number7461172
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: