Healthcare Provider Details

I. General information

NPI: 1265683445
Provider Name (Legal Business Name): POCATELLO ORTHOPAEDICS AND SPORTS MEDICINE INSTITUTE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2008
Last Update Date: 10/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 N 18TH AVE SUITE D-1
POCATELLO ID
83201-3358
US

IV. Provider business mailing address

333 N 18TH AVE SUITE D-1
POCATELLO ID
83201-3358
US

V. Phone/Fax

Practice location:
  • Phone: 208-233-2100
  • Fax: 208-233-3146
Mailing address:
  • Phone: 208-233-2100
  • Fax: 208-233-3146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: REBECCA J SMITH
Title or Position: OFFICE MANAGER
Credential:
Phone: 208-233-2100