Healthcare Provider Details

I. General information

NPI: 1679818025
Provider Name (Legal Business Name): EASTERN IDAHO REGIONAL MEDICAL CENTER INPATIENT SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2012
Last Update Date: 12/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2860 CHANNING WAY SUITE 100
IDAHO FALLS ID
83404-7531
US

IV. Provider business mailing address

2860 CHANNING WAY SUITE 100
IDAHO FALLS ID
83404-7531
US

V. Phone/Fax

Practice location:
  • Phone: 208-535-4566
  • Fax:
Mailing address:
  • Phone: 208-535-4566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RB0002X
TaxonomyObesity Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DAVID KANE
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 801-568-5933