Healthcare Provider Details

I. General information

NPI: 1407124753
Provider Name (Legal Business Name): IDAHO FALLS PULMONARY SLEEP & CRITICAL CARE SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2011
Last Update Date: 01/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2442 E 25TH ST
IDAHO FALLS ID
83404-7549
US

IV. Provider business mailing address

2442 E 25TH ST
IDAHO FALLS ID
83404-7549
US

V. Phone/Fax

Practice location:
  • Phone: 208-552-4909
  • Fax: 208-522-6101
Mailing address:
  • Phone: 208-552-4909
  • Fax: 208-522-6101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: ALLEN J SALEM
Title or Position: OWNER/DIRECTOR
Credential: MD
Phone: 208-552-4909