Healthcare Provider Details

I. General information

NPI: 1356475115
Provider Name (Legal Business Name): MICHAEL P KOELSCH MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 09/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 N 6TH E
MOUNTAIN HOME ID
83647-2207
US

IV. Provider business mailing address

PO BOX 940
MOUNTAIN HOME ID
83647-0940
US

V. Phone/Fax

Practice location:
  • Phone: 208-587-5880
  • Fax: 208-587-7905
Mailing address:
  • Phone: 208-587-5880
  • Fax: 208-587-7905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberM3819
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP382A
License Number StateID

VIII. Authorized Official

Name: MARY LOU KOELSCH
Title or Position: OFFICE MANAGER
Credential:
Phone: 208-587-5880