Healthcare Provider Details

I. General information

NPI: 1740325083
Provider Name (Legal Business Name): GRACE MARIE COBIELLA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 CHANNING WAY
IDAHO FALLS ID
83404-7533
US

IV. Provider business mailing address

3100 CHANNING WAY P.O. BOX 2077
IDAHO FALLS ID
83404-7533
US

V. Phone/Fax

Practice location:
  • Phone: 208-227-2100
  • Fax: 208-227-2361
Mailing address:
  • Phone: 208-227-2100
  • Fax: 208-227-2361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberM6214
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: