Healthcare Provider Details

I. General information

NPI: 1356485767
Provider Name (Legal Business Name): ELIZABETH HART SUGDEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2007
Last Update Date: 01/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 5TH AVE W
JEROME ID
83338-1825
US

IV. Provider business mailing address

PO BOX 587
TWIN FALLS ID
83303-0587
US

V. Phone/Fax

Practice location:
  • Phone: 208-324-5286
  • Fax: 208-324-9815
Mailing address:
  • Phone: 208-814-7400
  • Fax: 208-814-7491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM5431
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: