Healthcare Provider Details

I. General information

NPI: 1295728897
Provider Name (Legal Business Name): SCOTT ALAN BALDRIDGE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 11/07/2022
Certification Date: 11/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

365 MCKENNA DR
MOUNTAIN HOME ID
83647
US

IV. Provider business mailing address

515 E 17TH N
MOUNTAIN HOME ID
83647-1759
US

V. Phone/Fax

Practice location:
  • Phone: 208-587-9703
  • Fax:
Mailing address:
  • Phone: 208-587-0155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberO-333
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code207QS1201X
TaxonomySleep Medicine (Family Medicine) Physician
License Number009868
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: