Healthcare Provider Details

I. General information

NPI: 1861561094
Provider Name (Legal Business Name): THOMAS ERNEST PRYOR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 12/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 5TH AVE WEST
GOODING ID
83330
US

IV. Provider business mailing address

121 5TH AVE WEST
GOODING ID
83330
US

V. Phone/Fax

Practice location:
  • Phone: 208-934-4800
  • Fax: 208-934-9611
Mailing address:
  • Phone: 208-934-4800
  • Fax: 208-934-9611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM7337
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2011020656
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number46233
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: