Healthcare Provider Details

I. General information

NPI: 1003852849
Provider Name (Legal Business Name): CORTNEY A VANDENBURGH DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CORTNEY ANN GILBERTSON

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 02/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 AVIATION DR SUITE 100
HAILEY ID
83333-8785
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-788-3434
  • Fax: 208-788-2025
Mailing address:
  • Phone: 208-381-2222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberO0419
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMR0827
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: