Healthcare Provider Details

I. General information

NPI: 1992797088
Provider Name (Legal Business Name): ALLEN J SALEM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 11/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2442 E. 25TH ST.
IDAHO FALLS ID
83404-0000
US

IV. Provider business mailing address

2442 E. 25TH ST.
IDAHO FALLS ID
83404-0000
US

V. Phone/Fax

Practice location:
  • Phone: 208-552-4909
  • Fax: 940-612-3636
Mailing address:
  • Phone: 208-552-4909
  • Fax: 940-612-3636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberK9165
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberK9165
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License NumberK9165
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: