Healthcare Provider Details

I. General information

NPI: 1003278730
Provider Name (Legal Business Name): TYLER T BIRCH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2016
Last Update Date: 04/09/2020
Certification Date: 04/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 S EAGLE RD STE 3102
MERIDIAN ID
83642-6352
US

IV. Provider business mailing address

500 W FORT ST # 111R
BOISE ID
83702-4501
US

V. Phone/Fax

Practice location:
  • Phone: 208-706-5100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberO-1272
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: