Healthcare Provider Details

I. General information

NPI: 1003157801
Provider Name (Legal Business Name): IDAHO REGIONAL HAND & UPPER EXTREMITY CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2013
Last Update Date: 08/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 HOSPITAL WAY STE 710
POCATELLO ID
83201
US

IV. Provider business mailing address

444 HOSPITAL WAY STE 710
POCATELLO ID
83201-2745
US

V. Phone/Fax

Practice location:
  • Phone: 208-235-4263
  • Fax: 208-233-4268
Mailing address:
  • Phone: 208-235-4263
  • Fax: 208-233-4268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License NumberM-8547
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA-684
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License NumberO-0574
License Number StateID

VIII. Authorized Official

Name: DR. JEFFREY DEE STUCKI
Title or Position: PRESIDENT
Credential: DO
Phone: 208-235-4263