Healthcare Provider Details

I. General information

NPI: 1932532686
Provider Name (Legal Business Name): JASON P RICHARDS MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2013
Last Update Date: 08/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 HOSPITAL WAY STE 477
POCATELLO ID
83201-2744
US

IV. Provider business mailing address

444 HOSPITAL WAY STE 477
POCATELLO ID
83201-2744
US

V. Phone/Fax

Practice location:
  • Phone: 208-233-8344
  • Fax: 208-233-6983
Mailing address:
  • Phone: 208-233-8344
  • Fax: 208-233-6983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberM12138
License Number StateID

VIII. Authorized Official

Name: JASON P RICHARDS
Title or Position: OWNER
Credential: MD
Phone: 208-233-8344