Healthcare Provider Details

I. General information

NPI: 1689993271
Provider Name (Legal Business Name): DAVID LYLE HILL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2010
Last Update Date: 11/25/2020
Certification Date: 11/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 CHANNING WAY STE 304
IDAHO FALLS ID
83404-7546
US

IV. Provider business mailing address

PO BOX 742337
ATLANTA GA
30374-2337
US

V. Phone/Fax

Practice location:
  • Phone: 208-535-4567
  • Fax: 208-535-4569
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0-0718
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: