Healthcare Provider Details

I. General information

NPI: 1144300906
Provider Name (Legal Business Name): DORCHUCK MEDICAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 12/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 E MULLAN AVENUE
OSBURN ID
83849-0596
US

IV. Provider business mailing address

PO BOX 596
OSBURN ID
83849-0596
US

V. Phone/Fax

Practice location:
  • Phone: 208-556-4803
  • Fax: 208-556-1023
Mailing address:
  • Phone: 208-556-4803
  • Fax: 208-556-1023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-1871
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM-6906
License Number StateID

VIII. Authorized Official

Name: RONALD W DORCHUCK JR.
Title or Position: OWNER
Credential: MD
Phone: 208-556-4803