Healthcare Provider Details

I. General information

NPI: 1922026467
Provider Name (Legal Business Name): ROBERT TODD GILLESPIE P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 06/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 BANNOCK ST SUITE B
MALAD CITY ID
83252-1256
US

IV. Provider business mailing address

PO BOX 126 SUITE B
MALAD CITY ID
83252-0126
US

V. Phone/Fax

Practice location:
  • Phone: 208-766-2600
  • Fax:
Mailing address:
  • Phone: 208-766-2231
  • Fax: 208-766-4819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA205
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: