Healthcare Provider Details

I. General information

NPI: 1982738662
Provider Name (Legal Business Name): SOUTHEASTERN IDAHO MEDICAL CLINICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 W 200 N
MALAD CITY ID
83252-1109
US

IV. Provider business mailing address

2750 S 4100 W
MALAD CITY ID
83252-6542
US

V. Phone/Fax

Practice location:
  • Phone: 208-766-2267
  • Fax: 208-766-2342
Mailing address:
  • Phone: 208-766-4118
  • Fax: 208-766-2342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number0-41
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0-41
License Number StateID

VIII. Authorized Official

Name: STEPHEN CHARLES JOHNSON
Title or Position: MEDICAL DIRECTOR
Credential: D.O.
Phone: 208-766-2267