Healthcare Provider Details

I. General information

NPI: 1255383055
Provider Name (Legal Business Name): SAM G BATTAGLIA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 10/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1623 S WELLS AVE
MERIDIAN ID
83642-5040
US

IV. Provider business mailing address

1130 E FAIRVIEW AVE
MERIDIAN ID
83642-1813
US

V. Phone/Fax

Practice location:
  • Phone: 208-489-1450
  • Fax: 208-489-1451
Mailing address:
  • Phone: 208-985-1399
  • Fax: 208-955-6501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM8918
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: