Healthcare Provider Details

I. General information

NPI: 1013981604
Provider Name (Legal Business Name): GLENN DAVID RYCH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 10/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

623 S MAIN ST
MOSCOW ID
83843-2983
US

IV. Provider business mailing address

623 S MAIN ST
MOSCOW ID
83843-2983
US

V. Phone/Fax

Practice location:
  • Phone: 208-882-2011
  • Fax: 208-883-1853
Mailing address:
  • Phone: 208-882-2011
  • Fax: 208-883-1853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM4592
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: