Healthcare Provider Details

I. General information

NPI: 1124115944
Provider Name (Legal Business Name): TONY C ROISUM MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 01/16/2026
Certification Date: 01/16/2026
Deactivation Date: 07/24/2007
Reactivation Date: 12/09/2008

III. Provider practice location address

3360 WASHINGTON PKWY SUITE 1
IDAHO FALLS ID
83404-8333
US

IV. Provider business mailing address

3360 WASHINGTON PKWY STE 1
IDAHO FALLS ID
83404-7592
US

V. Phone/Fax

Practice location:
  • Phone: 208-524-3416
  • Fax: 208-524-3138
Mailing address:
  • Phone: 208-524-3416
  • Fax: 208-524-3138

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM7389
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberM7389
License Number StateID

VIII. Authorized Official

Name: JACQUELINE KELSEY
Title or Position: OFFICE MANAGER
Credential:
Phone: 208-524-3416