Healthcare Provider Details

I. General information

NPI: 1184496051
Provider Name (Legal Business Name): IDAHO HEART PHYSICIAN GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

2985 CORTEZ AVE
IDAHO FALLS ID
83404-7554
US

IV. Provider business mailing address

955 PIER VIEW DR
IDAHO FALLS ID
83402-4918
US

V. Phone/Fax

Practice location:
  • Phone: 208-523-3373
  • Fax: 208-523-8746
Mailing address:
  • Phone: 208-557-5218
  • Fax: 208-529-9732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN CHAMBERS
Title or Position: PRESIDENT
Credential: MD
Phone: 208-403-1127