Healthcare Provider Details

I. General information

NPI: 1043492655
Provider Name (Legal Business Name): TOTAL HEALTH PHYSICIAN GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2007
Last Update Date: 03/11/2021
Certification Date: 03/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

619 S WASHINGTON ST SUITE 203
MOSCOW ID
83843-3090
US

IV. Provider business mailing address

619 S WASHINGTON ST STE 203
MOSCOW ID
83843-3063
US

V. Phone/Fax

Practice location:
  • Phone: 208-892-1346
  • Fax: 208-892-8306
Mailing address:
  • Phone: 208-892-1346
  • Fax: 208-892-8306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. ROBERT N SPADY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 208-892-1346